Integrating Research, Evidence-Based Practice, and Quality Improvement Processes Geri LoBiondo-Wood, Judith Haber Go to Evolve at http://evolve.elsevier.com/LoB iondo/ for review questions. LEARNING OUTCO MES After reading this chapter, you should be able to do the following: • State the significance of research, evidence-based • Explain the difference between types of systematic practice, and quality improvement (QI). reviews. • Identify the role of the consumer of nursing • Discuss how to use an evidence hierarchy when research. critically appraising research studies. • Differentiate among research, evidence-based • Discuss the format and style of research reports/ practice, and QI. articles. • Discuss evidence-based and QI decision making. • Explain the difference between quantitative and qualitative research. KEY TERMS abstract clinical guidelines consensus guidelines cri tical appraisal evidence-based guidelines evidence-based practice integrative review levels of evidence meta-analysis meta-synthesis quality improvement qualitative research quantitative research research systematic review We invite you to join us on an exciting nursing research adventure that begins as you read the first page of this chapter. The adventure is one of discovery! You will discover ttat the nursing research literature sparkles with pride, dedication, and excitement about t is dimension of professional practice. As you progress through your nursing program, yo~ a~: taught how to ensure quality and safety in clinical practice by acquiring knowledge O t . various sciences and health care principles. A critical component of clinical knowledge is understanding research as it applies to practicing from an evidence base. 8 CHAPTER 1 Integrating Research, EBP, and QI Processes l.,._J Whether you are a student or a practicing nurse whose goal is to use research as the foundation of your practice, you will discover that research, evidence-based practice (EBP}, and quality improvement (QI) position our profession at the cutting edge of change and improvement in patient outcomes. You will also discover the cutting-edge "who;' "what;' "where;' "when;' "why;' and "how" of research that help you develop a foundation of EBP knowledge and competencies that will equip you for clinical practice. Your nursing research adventure will be filled with new and challenging learning experiences that develop your EBP skills. Your critical appraisal skills and clinical decision-making skills will expand as you develop clinical questions, search the research literature, evaluate the research evidence found in the literature, and make clinical decisions about applying the "best available evidence" to your practice. For example, you will be encouraged to ask important clinical questions, such as, • What makes a telehealth education intervention more effective with one group of patients with a diagnosis of congestive heart failure but not another? • What is the effect of e-learning health literacy modules on self-management of diabetes in children? • What research has been conducted to identify barriers to breast cancer screening in African American women? • What is the quality of studies conducted about the effectiveness of motivational interviewing in promoting behavioral lifestyle changes for populations at high risk for hypertension? , Which nurse -delivered smoking cessation interventions are most effective? This book will help you begin your adventure into EBP by developing an appreciation of research as the foundation for EBP and QI. NURSING RESEARCH, EVIDENCE-BASED PRACTICE, AND QUALITY IMPROVEMENT Nurses are challenged to stay abreast of new information to provide the highest quality of patient care (Institute of Medicine [IOM], 201 I). Nurses are challenged to expand their "comfort zone" by offering creative approaches to old and new health problems and designing new and innovative programs that make a difference in the health status of targeted populations across the life span. These challenges can best be met by integrating rapidly expanding research and evidence-based knowledge about biological, behavioral, and environmental influences on health into the care of patients and their families. It is important to differentiate among research, EBP, and QI. Research is a systematic, rigorous, critical investigation that aims to answer questions about health-related phenomena. Researchers follow the steps of the scientific process, which are outlined in this chapter and discussed in detail in each chapter of this text. There are two types of research: quantitative and qualitative. The methods used by nurse researchers are the same methods used by other disciplines; the difference is that nurses study questions relevant to nursing practice. Published research studies read and evaluated for applicability to practice are used to inform clinical decisions. Evidence-based practice is the collection, evaluation, and integration of valid research evidence, combined with clinical expertise and an understanding of patient and family values and preferences, to inform clinical decision making (Sackett et al., 2000) . Research studies are gathered from the literature, and the findings are assessed so evidence-based illW :mas CHAPTER 1 Integrating Research, EBP, and QI Processes ij] evidence. These topics are designed to help you read research articles more effectively and with greater understanding so you can make evidence-based clinical decisions and contribute to quality and cost-effective patient outcomes. TYPES OF RESEARCH: QUALITATIVE AND QUANTITATIVE Research is classified into two major categories: qualitative and quantitative. A researcher chooses between these categories based on the question being asked. That is, a researcher may wish to test a cause-and-effect relationship, assess if variables are related, or discover and understand the meaning of an experience or process. A researcher would choose to conduct a qualitative research study if the question is about understanding the meaning of a human experience such as grief, hope, or loss. The meaning of an experience is based on the view that meaning varies, is subjective, and occurs in a context. That is, the experience of loss as a result of a miscarriage would be different than the experience of losing a parent. Qualitative research is generally conducted in natural settings and uses data that are words or text rather than numeric to describe the experiences being studied. Qualitative studies are guided by research questions, and data are collected from a small number of subjects, allowing an in-depth study of a phenomenon. Example: Hanna et al. (2020) explored the perceptions that underlie health-related adherence behaviors from the perspective of patients who experienced a heart attack (see Appendix E). Although qualitative resea rch is systematic in its method, it uses a subjective approach . Data from qualitative studies help nurses understand experiences or phenomena that affect patients; these data also assist in generating theories that lead clinicians to develop improved patient care and stimulate further research. Highlights of the general steps of qualitative studies and the jo urnal format for a qualitative article are outlined in Table l. l. Chapters 5 to 7 provide an in -depth view of qualitative research underpinnings, designs, and methods. TABLE ' 1 :·V - Steps of the Research Process and Journal Format: Qualitative Research Research Process Steps and/or Format Issues Usual Location in Journal Heading or Subheading Identifying the phenomenon Research question or study purpose Literature review Design Abstract and/or in introduction Abstract and/or in beginning or end of introduction Introduction. background and/or discussion Abstract and/or in introductory section or under method section entitled '"Design" or stated in method section Method section labeled ··sample" or ··subjects" Data collection or procedures section or in sample section Methods section includes instruments used and their reliability and validity Data collection or procedures section Methods section under subhead "Data Analysis" or '"Data Analysis and Interpretation·· Stated in separate heading: "Results·· or "Findings" Combined in separate section: "Discussion" or "Discussion and Implications" At end of article Sample Legal-ethical issues Measurement Data collection procedure Data analysis Results Discussion and recommendation References CHAPTER 1 Integrating Research, EBP, and QI Processes Toe primary difference is that qualitative research seeks to interpret meaning and phenomena, whereas quantitative research seeks to test a hypothesis or answer research questions using statistical methods. Remember as you read research articles that, depending on the research question, a researcher may vary the steps slightly; however, each step should be addressed systematically. CRITICAL APPRAISAL SKILLS To develop expertise in EBP, you will need to be able to critically evaluate all types of research articles. As you read a research article, you may be struck by the difference in style or format of a research article versus a clinical article. The terms of a research art icle are new, and the content is different. You may also be thinking that the research art icle is hard to read or that it is technical and boring. You may simultaneously wonder, "How will I possibly learn to appraise all of the steps of a research study, the terminology, and th e process of EBP? I'm only on Chapter I. This is not so easy; research is as hard as everyone says:' Lea rning the research process develops your critical appraisal skills. You will gradually be able to read a research article and determine whether the conclusions are based on the study's fi ndi ngs. Once you have obtained this critical appraisal competency, you will be rea dy to synthesize the findings of multiple studies to use in developing an EBP. Start an rnterprofessional education journal club wi th students from other health professions programs on your campus Select a research study to read, understand. and critically appraise together. It is always helpful to collaborate on deciding whether the findings are applicable to clinical practice. STRATEGIES FOR APPRAISINGRESEARCH STUDIES Critical appraisal of a study objectively and critically evaluates a study's content for its strengths and weaknesses and overall applicability to practice. It requires some knowledge of the subject matter and knowledge of how to use critical appraisal criteria. In this text, you will find: • Summarized examples of critical appraisal criteria for qualitative studies and an example of a qualitative critique in Chapter 7 • Summarized critical appraisal criteria and examples of a quantitative critique in Chapter 18 • An in-depth exploration of the criteria for evaluation required in quantitative research in Chapters 8 to 18 • Criteria for qualitative research in Chapters 5 to 7 • Principles for qualitative and quantitative research in Chapters 1 to 4 Critical appraisal criteria are the standards, appraisal guides, or questions used to evaluate an article. When analyzing a research article, you must evaluate each step of the research process and ask questions about whether each step meets the criteria. For instance, the critical appraisal criteria in Chapter 3 ask if "the literature review identifies gaps and inconsistencies in the literature about a subject, concept, or problem;' and if "all of the concepts and variables are included in the review:' These two questions relate to appraising the research CHAPTER 1 Integrating Research, EBP, and QI Processes Level I Syslematlc review or meta-analysis of randomized controlled trials (RCTs) Level II Randomized controlled trials Level Ill Quasiexperimental studies Level IV Nonexperimentai studies Level V Metasynthe si s I / I I I - Level VI Qualitative studies - -- - - -- - - - - - - - \ Level VII Opinion of experts and authorities , expert committee reports or organizations, not based on research FIG 1.1 Levels of Evidence. Evidence hierarchy for rating levels of evidence associated with a study's design. Evidence is assessed at a level according to its source. Act (ACA) involves considering interventions that are affordable, accessible, available, and culturally congruent with the targeted community. EBP involves processes and steps, as does the research process. These steps are presented throughout the text. Chapter 19 provides an overview of EBP steps and strategies. When using EBP strategies, the first step is to be able to read a study with an understanding of how each section is linked to the steps of the research process. The following section introduces you to the research process as presented in published articles. Once you read a study, you must decide which level of evidence the study provides and how well the study was designed and executed. Fig. 1.1 illustrates a model for determining the levels of evidence associated with a study's design, ranging from systematic reviews of randomized controlled trials (RCTs) (see Chapters 9 and 10) to expert opinions. The rating system, or evidence hierarchy model, presented here is just one of many. Many hierarchies for assessing the relative worth ofboth qualitative and quantitative designs are available. Early in the development ofEBP, evidence hierarchies were thought to be very inflexible, with systematic reviews or meta-analyses at the top and qualitative research at the bottom. This is no longer the case. There is no guarantee that a Level II RCT with design flaws will provide stronger evidence than a well-designed Level III cohort study. CHAPTER 1 Integrating Research, EBP, and QI Processes ffi review of these guidelines, which are found on a journal's website, will give you an idea of the format of articles that appear in specific journals. Remember that even though each step of the research process is discussed at length in this text, you may find only a short paragraph or a sentence in an article that provides the details of the step. A publication is a shortened version of the researcher(s) completed work. You will also find that some researchers devote more space in an article to the results, whereas others present a longer discussion of the methods and procedures. Decisions about the amount of material presented for each step of the research process are bound by the following: • The journal's space limitations • The journal's author guidelines • The type or nature of the study The researcher's decision regarding which component of the study is most important The following discussion provides a brief overview of each step of the research process and how it m ay appear in an article. It is important to remember that a quantitative research article will differ from a qualitative research article. The components of qualitative research are discussed in Chapters 5 and 6 and are summarized in Chapter 7. Abstract An abstract is a short, comprehensive synopsis or summary of a study at the beginning of an article. An abstract quickly focu ses the reader on the main points of a study. A well -presented abstract is accurate, self-contained, concise, specific, nonevaluative, coherent, and readable. Abstracts vary in word length. The length and format of an abstract are dictated by the journal's style. Both quantitative and qualitative research studies have abstracts that provide a succinct overview of the study. Examples of abstracts can be found in each of the articles in the appendices. An abstract is a concise shon overvi ew that provides a reference to the research purpose. research questions, hypotheses, methodology, resu lts, and implications for practice or future research. Introduction/Study Purpose Early in a research article, in a section that may or may not be labeled "Introduction;' or "Purpose;' the researcher presents a background picture of the area researched and its significance to practice (see Chapter 2) . The study's purpose may or may not be labeled (see Chapters 2 and 3), or it may be referred to as the study's aim or objective. The studies in Appendices A to E present specific purposes for each study in untitled sections that appear in the beginning of each article and in the article's abstract. Literature Review and Theoretical Framework Authors of studies present the literature review and theoretical framework in different ways. Many research articles merge the "Literature Review" and the "Theoretical Framework:' This section includes the main concepts investigated and may be called "Review of the Literature:• "Literature Review;• "Theoretical Framework;' "Related Literature;• "Background;' "Conceptual Framework;' or it may not be labeled at all (see Chapters 2 and 3). One style is not better than another; the studies in the appendices contain all of the critical elements but present the elements differently. CHAPTER 1 Integrating Research, EBP. and 01 Processes 'ill) understand how to link the levels of evidence with quantitative designs. A study may not indicate the specific design used; however, all studies inform the reader of the methodology used, which can help you decide the type of design the authors used to guide the study. Sampling The population from which the sample was drawn is discussed in the section "Methods" or "Methodology" under the subheadings of "Subjects" or "Sample" (see Chapter 12). Researchers should identify for you the population from which the sample was chosen, the inclusion criteria, the number of subjects who participated in the study, and a description of subjects who dropped out of the study. The authors of the studies in the appendices discuss their samples in enough detail so the reader is clear about who the subjects are and how they were selected. Reliability and Validity A discussion of the instruments used to study the variables is usually included in a "Methods" section under the subheading of"Instruments" or "Measures" (see Chapter 14). Usually a discussion of each instrument (or scale) used in the study along with its reliability and validity is included (see Chapter 15). The studies in the appendices discuss each of the measures used in the "Methods" section under the subheading "Measures" or "Instruments;• "tools and data collection;• and "outcome measures and data collection:' Toe reliability and validity of each measure is not always presented, but references with this information are usually cited. Procedures and Data Collection Methods The data collection procedures, or the individual steps taken to gather measurable data (usually with instruments or scales), are generally found in the "Procedures" or "Data Collection" section (see Chapter 14). Notice that the researchers in the studies in the Appendices provided information that the studies were approved by an institutional review board (see Chapter 13), thereby ensuring that each study met ethical standards. Data Analysis/Results Data analysis procedures (i.e., the statistical tests used and the results of descriptive and/ or inferential tests applied in quantitative studies) are presented in the "Results" or "Findings" section (see Chapters 16 and 17). Although qualitative studies do not use statistical tests, the procedures for analyzing the themes, concepts, and/or observational or print data are usually described in the "Method" or "Data Collection" section and reported in the "Results;' "Findings;• or "Data Analysis" section (see Appendix E and Chapters 5 and 6). Discussion The last section of a research study is the "Discussion" section (see Chapter 17). In this section, the researchers tie together all of the study's components and give a wholistic picture of the study. The researchers return to the literature reviewed and discuss how their study is similar to or different from other studies. Researchers may report the results and discussion in one section but usually report their results in separate "Results" and "Discussion" sections (see Appendices A to E) . One particular format is no better than another. Journal and space limitations determine how these sections will be handled. Any new or unexpected findings are usually described in the "Discussion" section. CHAPTER 1 Integrating Research, EBP, and QI Processes El] terms systematic review and integrative review interchangeably. Both a meta-synthesis and meta-summary are the synthesis of a number of qualitative research studies on a focused topic using specific qualitative methodology (Kastner et al., 2016; Sandelowski & Barrosos, 2007). The components of review articles will be discussed in greater detail in Chapters 6, 11, and 20. These articles take a number of studies related to a clinical question and, using a specific set of criteria and methods, evaluate the studies as a whole. Although they may vary somewhat in approach, these reviews all help better inform and develop EBP. The meta-analysis in Appendix E is an example of a systematic review that is a meta-analysis. CLINICAL GUIDELINES Clinical guidelines are systematically developed statements or recommendations that serve as a guide for practitioners. Two types of clinical guidelines will be discussed throughout this text: consensus, or expert-developed guidelines, and evidence-based guidelines. Consensus guid elines, or expert-developed guidelines, are developed by an agreement of experts in the field. Evidence-based guidelines are those developed using published research findings. Guidelines are developed to assist in bridging practice and research and are developed by professional organizations, government agencies, institutions, or convened expert panels. Clinical guidelines provide clinicians with an algorithm for clinical management or decision making for specific diseases (e.g., breast cancer) or treatments (e.g., pain management). Not all clinical guidelines are well developed and, like research, must be assessed before implementation. Though they are systematically developed and make explicit recommendations for practice, clinical guidelines may be formatted differently. Guidelines for practice are becoming more important as third-party and government payers are requiring practices to be based on evidence. Guidelines should present the scope and purpose of the practice, detail who the development group included, demonstrate scientific rigor, be clear in its presentation, demonstrate clinical applicability, and demonstrate editorial independence (see Chapter 11 ). QUALITY IMPROVEMENT As a health care provider, you are responsible for continuously improving the quality and safety of health care for your patients and their families through systematic redesign of health care systems in which you work. The !OM (201 I) defined quality health care as care that is safe, effective, patient-centered, timely, efficient, and equitable. Therefore the goal of QI is to bring about measurable changes across these six domains by applying specific methodologies within a care setting. Although several QI methods exist, the core steps for improvement commonly include the following: • Conducting an assessment • Setting specific goals for improvement • Identifying ideas for changing current practice • Deciding how improvements in care will be measured Rapidly testing practice changes Measuring improvements in care Adopting the practice change as a new standard of care CHAPTER 1 Integrating Research, EBP, and QI Processes EI) • A number of different components are usually identified in a research article. Discuss how these sections link with one another to support the researcher's conclusions and recommendations. How can QI data be used to improve clinical practice? REFERENCES Agency for Healthcare Research and Quality. (2002). Systems to rate the strength of scientific evidence. File inventory, Evidence Report/Technology Assessment No. 47, AHRQ Publication No. 02-E0!6. American Nurses Association (ANA). (20 I 5). Code of ethics for nurses for nurses with interpretive state111en ts. Washington, DC: The Association. Cochrane Consumer Network, The Cochrane Library, 2020, retrieved online. www.cochranelibrary.com. Cronemvett, L., Sherwood, G., Barnsteiner, )., et al. (2007). Quality and safety education for nurses. N11rsi11g Outlook, 55(3), 122-131. De la Fuente Coria, M. C., Cruz-Cobo, C., & Santi -Cano, M. ). (2020). Effectiveness of a primary c~re nurse delivered educational intervention for patients with a type 2 diabetes mellitus in promoting m~tabolic control and compliance with long term therapeutic targets: Randomised controlled trial. International Journal of Nursing Studies, 101, 1-10. https://doi.org/10.1016/j .ijnurstu.2019.103396. http:/ /dx.doi.org/. Facchinelli, G., D'Angelo, D., Piredda, M., Petitti, T., Matarese, M., Oliveti, A., & Grazia DeMarinis, M. (2020). Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis. International journal of Nursing Studies, 1-10. https:// doi.org/ IO. IO 16/j.ijnurstu.2019. 103396. Gupta, N., Vujicic, M., Yarborough, C., & Harrison, B. (2018). Disparities in untreated caries among children and adults in ihe U.S., 2011-2014. BMC Oral Health, 1-9. https://doi.org/10.1186 /s 12903-018-0493-7. Hanna, A.. Yael, E-m, Hadassa, L., Iris, E., Eugenia, N., Lior, G., Carmi!, S., & Liora, 0 (2020). It's up to me with a little support" - Adherence after myocardial infraction: A qualitative study. International Journal of Nursing Studies. https:/ /doi.org/ IO. IO 16/ijnurstu.2019. 103416. Institute of Medicine IIOM] . (2011). The future of nursing: leading change, advancing health. Washington, DC: National Academic Press. Kastner, M., Antony,)., Soobiah, C., el al. (2016). Conceptual recommendations for selecting the most appropriate knowledge synthesis method to answer research questions related to complex evidence. Journal of Clinical Epidemiology, 73, 43- 49. Sackett, D. L., Straus, S., Richardson, S., et al. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). London: Churchill Livingstone. Sandelowski, M., & Barroso,). (2007). Handbook of qualitative research. New York: Springer. Uman, L. S. (2011 ). Systematic reviews and meta-analyses. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 20(1), 57-59. Whittemore, R. (2005). Combining evidence in nursing research. Nursing Research, 54(1 ), 56-62. Go to Evolve at http://evolve.elsevi er.com/LoBiondo/for review questions, appraisal exercises, and additional re search articles for practice in reviewing and appraisal.
