N371 Exam #1 – Flashcards

*Without it, we are really just guessing about what works well, what to do, what will not harm...* "Bleeding" therapy for ill patients in the 1800's "Vapors" as cause of cholera in London Diethylstilbestrol (DES) exposure from 1938 - 1971

1) Understand and ease symptoms 2) Prevent, delay or slow disease and disability 3) Improve quality of life and well-being 4) Eliminate health disparities -Disproportionate illness burden, poorer outcomes given health determinants (e.g., physical environment, genetic predisposition, socioeconomic factors, discrimination factors, available social networks, access to care) 5) Improve care in clinical settings 6) Improve nursing education ; professional socialization

1) *Associate degree programs* (e.g., ADN): no research-focused content mandated by accrediting bodies. 2) *Baccalaureate programs* (e.g., BSN): basic understanding of research process, identify problems, collaborate on research teams, apply findings in practice and research 3) *Masters programs* (e.g., MSN): prepare nurses to evaluate research findings, develop and implement evidence-based practices, identify problems, collaborate with scientists to initiate research 4) *Practice-focused doctorate programs* (e.g., DNP): prepare nurses to translate research into practice and collaborate with scientists to evolve translation and evaluation into health policies. 5) *Research-focused doctorate programs* (e.g., PhD): prepare nurses to conduct independent knowledge-generating research, and to involve other nurses in that work 6) *Post-doctoral programs* (e.g., T32 Post-doctoral Fellow): provide PhD-prepared nurses with 2 years of additional time to develop their research skills and their science under mentorship of experienced scientists.

*Arise in practice, clinical experiences, patient encounters* Theoretical ; Patient-Situation Specific 1) PICO/PICOT = *"Background"* -->Theoretical -Why is aseptic technique important when caring for open wounds? 2) PICO/PICOT - *"Foreground"* --> Patient-Situation Specific -In diabetic patients with venous stasis ulcers on their lower extremities, what is the best topical medication to apply to regenerate tissue? Different from *research* questions: -These ask what is already known about "X", rather than asking a question that generates new knowledge about "X"

1) Focus on "pathfinders" 2) Violent/abusive behavior within relationships not considered a 'health' issue, but a criminal justice one (up to 1980s). 3) Nursing research contributions to moving Domestic Violence from overlooked problem to routine clinical practice.

1) No word, or term, for "domestic violence" in the 1980s. 2) Injuries overlooked, not questioned. 3) "Root causes", or etiology, not addressed. 4) Nurses began identifying frequency, risks for, and patterns of injuries informally in practice settings. 5) Questions about injuries emerged from practice. Nurse researchers applied scientific methods to define, understand, assess at individual level.

1) Pain viewed as unavoidable, inconsequential phenomenon. 2) Nurses witnessed most frequently in patients, without responsive healthcare system. 3) Breakthroughs in pain management

Report that takes individual studies and combines them and synthesizes them. Very structured!

Similar to systemic review, but better than the systematic review. It takes it one step further by combining all the data and reanalyzing the statistics.

Guidelines do the same thing the reviews do, but they also include a whole section about *implementation* of the guidelines.

1) Critical appraisal and synthesis of the most relevant and best research (*external evidence*) 2) One's own *clinical expertise*, which includes *internal evidence* generated from outcomes management or quality improvement projects, patient assessment, and evaluation 3) *Patient preferences and values*

1) *External evidence:* (Generalizability) -Evidence generated through rigorous research (e.g., RCTs and cohort studies) that is intended to be generalized to and used in other settings. 2) *Internal evidence:* -Evidence typically generated through practice initiatives such as outcomes management or quality improvement projects that are not intended to be generalized to other clinical settings.

*True* -It has been reviewed! Therefore, it is true. -Rationale: External evidence includes peer-reviewed publications that present the findings of research and are intended to be generalized to other clinical settings.

1) Concept began when Dr. Archie Cochrane published a report in 1972 for the Nuffield Provincial Hospitals Trust that demonstrated how slow the medical profession was in using published evidence to change practice. 2) Cochrane Center Collaboration was established in 1992 in his name to assist healthcare professionals in making clinical decisions based on the best external evidence. 3) One of the best known sources of systematic reviews website: http://www.cochrane.org

1) Enhancing the experience of care for those served 2) Improving the health of populations throughout the nation 3) Reducing per capita costs of national health care

0) Cultivate a spirit of inquiry within the environment 1) Ask the burning clinical question in PICOT format 2) Search for and collect the most relevant best evidence 3) Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis) 4) Integrate the best evidence with one's clinical expertise and patient preferences and values in making a practice decision or change 5) Evaluate outcomes of the change 6) Disseminate the outcomes of the evidence-based change

Key elements of an EBP culture and environment include: 1) A spirit of inquiry 2) A philosophy, mission, clinical promotion system, and evaluation process that incorporate EBP 3) Knowledgeable EBP mentors 4) An infrastructure that provides support in using EBP 5) Administration and leadership that supports, values, and models EBP 6) Consistent recognition of individuals and groups who implement EBP

*P*atient population *I*ntervention or issue of interest *C*omparison intervention *O*utcome *T*ime frame

*False* Rationale: Meta-analyses and systematic reviews that synthesize the results of multiple RCTs or experiments are considered to be the highest form of evidence.

Critical appraisal of external evidence includes three areas of evaluation: 1) Are the results of the study *valid*? 1.a. Did the researchers conduct the study using the best research design and methods possible? 2) Are the results *reliable*? -In quantitative research --> Did the intervention work, and if so, how large was the effect? Can the results be generalized? -In qualitative research -->Does the research approach fit the purpose of the study? 3) Are the results *applicable* to my patients?

1) Synthesis of the external and internal evidence, the practitioner expertise, and the patient/family preferences that produces the implementation of a practice change 2) Patients' histories and circumstances have a significant bearing on the choice of practice changes 3) Availability of resources must also be considered

A) Review the literature about fetal monitoring practices B) Consult with the expert nurses on the unit C) *Begin to foster an attitude of curiosity in the OB staff* D) Evaluate the outcomes of current practices

Outcomes measurement determines whether the evidence-based change resulted in the expected outcome in the clinical practice setting *Assess --> Plan & Design --> Implement --> Evaluate*

1) For change to be sustainable, outcomes need to be shared with project stakeholders 2) Internal communication strategies can include e-mail messages, reports at unit/department meetings, dashboards, and scorecards 3) External communication strategies include podium or poster presentations at conferences and professional publications

A) *Tell others about the results of their project* B) Elicit feedback from patients and other stakeholders C) Evaluate the costs of the change in practice D) Search the literature for research that relates to the practice change Rationale: The EBP process culminates with the dissemination of results. Searching the literature, consulting with patients, and evaluating costs are actions that should already have been performed earlier in the EBP process.

-Lack of administrative/management support and mentors -Resistance to change -Misperceptions or negative attitudes about EBP -Lack of EBP knowledge and skills -Lack of autonomy over practice and lack of incentives

-Establishing a clear philosophy and organizational vision in which EBP is valued and expected -Developing a strategic plan to create a culture and environment that fosters EBP -Dispelling misperceptions about EBP -Teaching the basics of EBP -Encouraging questions about currently used clinical practices

A) Study validity, study veracity, study strength B) Study validity, study reliability, study confidence C) *Study validity, study reliability, study applicability* D) Study validity, study strength, study reproducibility Rationale: Terms in the incorrect distractors include study strength, which is actually derived from the study validity and reliability; study confidence, which results from the appraisal of the strength of the study; and study reproducibility, which is a component of study reliability.

-Lack of proficiency in using computers -Lack of computer access at point of care -Low comfort level/lack of skill using search techniques -Lack of access to appropriate electronic databases -Lack of time to search for the best evidence

*Background questions* *Asks for general information about a clinical issue *Usually has two components:* 1) The starting place of the question (e.g., what, where, when, why, and how) 2) The outcome of interest *Broader in scope than a foreground (PICOT) question* Example: "How does the drug acetaminophen work to affect fever?" ------------------------------------------- *Foreground questions (PICOT format)* -Asks for specific scientific evidence about diagnosing, treating, or educating patients -The focus is on specific knowledge Example: "In children aged 3 to 8 years, how does acetaminophen compare with ibuprofen in lowering a fever?"

*False* Rationale: Foreground questions are clinical questions that can only be answered by specific scientific evidence that is usually found in original studies or systematic reviews of original studies (e.g., RCTs). This type of evidence is not available in textbooks, which are more appropriate for answering background questions.

*Types of foreground questions* 1) Intervention questions (What intervention most effectively *leads* to an outcome?) 2) Prognosis/prediction questions (What indicators are most *predictive* of an outcome?) 3) Diagnosis questions (What test most accurately *diagnoses* an outcome?) 4) Etiology questions (To what extent is a factor *associated with* an outcome?) 5) Meaning questions (How does an experience *influence* an outcome?)

*True* Rationale: A PICOT question should always specify the outcome that is expected from the clinical question. It is important that the outcome be measurable in some way so that the effectiveness of the change can be evaluated.

*P*: Population of interest *I*: Intervention or issue of interest *C*: Comparison of interest *O*: Outcome expected *T*: Time needed for the intervention to achieve the outcome or the time in the course of the disease/symptom that the intervention is applied

D) *T (Time)*

c) *Individuals who require peritoneal dialysis*

a) *O*

1) Primary --> Studies/Experience -Search here second 2) Secondary--> Systematic reviews,meta-analysis -Search here first 3) Tertiary --> Becomes common knowledge

Systemic review --> Includes list of databases and the types of studies

Randomized Controlled Trial (primary)

Secondary analysis is not a systemic review.... It is a using the data from a primary study, but in a different way, therefore it is a *Primary Study*

1) Use synonyms, acronyms, and opposites 2) Put similar terms/synonyms in the same search box separated by OR 3) Searching for several variations of a word? Cut off the ending and add an asterisk to search for all variations. 4) Using one concept with multiple words? Have the database search for them next to each other by adding double quotes.

1) The Find@UNC button will allow you to get articles -From another library through Interlibrary Loan -Free for you -About 2-3 days -Don't settle for lesser articles!

1) Purpose is to generate *new knowledge* that can be generalized (applied) far and wide 2) Very rigorously conducted 3) Answers questions none of us have the answers to

Purpose is to *begin/change practice* by integrating findings from research studies so new practices are encouraged to be used, and consistently applied. 1) Study conducted by researchers at Kaiser Permanente in California shows less post-op nausea if "X" occurs 2) Hospitals around the country work to implement "X" 3) There may be some 'investigation' of how to best implement "X" on your unit, but that isn't "research", it is just trying to figure out how to best implement this new practice.

Purpose is to *assess how much "Y"(severe post-op nausea) occurs* on your unit/in your practice setting or *to assess how well implementation of new practice "X" is working.* 1) Is severe post-op nausea a "problem" on our unit? How often is it occurring? 2) Oh, a lot, hmm? 3) Implement "X" . . . and then 4) Document whether post-op nausea is improved after implementing practice. Periodically "monitor" to be sure it isn't getting worse again.

a) Wound care b) *Domestic violence* c) Tube feeding practices d) *Pain control*

*False* BSN take a class on EBP, and AND's don't.

A) hey are all RNs, and able to equally contribute B) *There will be vastly different levels of understanding around how to assess the strength of evidence.* C) Any RN in the group is equally capable of leading the task force members through the PICOT, literature search, and assessment steps. D) *You are probably much better positioned to lead the work of this group than one of your ADN colleagues.*

1) Synthesis of the external and internal evidence, the practitioner expertise, and the patient/family preferences that produces the implementation of a practice change 2) Patients' histories and circumstances have a significant bearing on the choice of practice changes 3) Availability of resources must also be considered

*True* Rationale: External evidence includes peer-reviewed publications that present the findings of research and are intended to be generalized to other clinical settings.

*C) The Cochrane Collaborative Database*

*External evidence* -Rigor -Purpose (generalized knowledge vs. limited application) -Peer review/where published -IRB review