research EBP – Flashcards
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Individuals with which of the following personality styles are most likely to be comfortable in a leadership role? A. D B. I C. S D. C
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A. D Individuals with "D" (Driver) personality styles like to take charge of projects and are highly task oriented, making them well-suited to positions of leadership.
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What model of organizational change would be most likely to prioritize changing nurses' feelings over presenting them with new information? A. The Transtheoretical Model of Health Behavior Change B. Kotter and Cohen's Model of Change C. The Change Curve Model D. Diffusion of Innovations Model
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B. Kotter and Cohen's Model of Change Rationale: Kotter and Cohen proposed that the key to organizational change lies in helping people to feel differently (i.e., appealing to their emotions). They assert that individuals change their behavior less when they are given facts or analyses that change their thinking than when they are shown truths that influence their feelings.
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T/F: A SCOT analysis helps clarify the goals and beliefs that underlie a proposed change to EBP.
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False Rationale: A SCOT analysis aids in the strategic planning for the execution of proposed change. Identification of the goals and beliefs that inform the change should take place prior to formal strategic planning.
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Feedback loops are a central component of which of the following models for evidence-based practice change? A. The Model for Evidence-Based Practice Change B. The Clinical Scholar Model C. The ARCC Model D. The Iowa Model
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D. The Iowa Model Rationale: The Iowa Model includes multiple feedback loops that refer the user back to earlier points in the process. This is not a central feature of the ARCC Model, the Clinical Scholar Model, or The Model for Evidence-Based Practice Change.
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T/F: Both The Model for Evidence-Based Practice Change and the Iowa Model include the use of a small-scale pilot study during the process of introducing an evidence-based change in practice.
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True Rationale: Pilot studies are explicit components of both The Model for Evidence-Based Practice Change and the Iowa Model.
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When the Stetler Model is used to guide an evidence-based practice change, which of the following activities will constitute the final phase of the process? A. Disseminating the results of the practice change B. Publishing the findings that result from implementation C. Evaluating the outcomes of the change in practice D. Implementing a change in practice based on evidence
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C. Evaluating the outcomes of the change in practice Rationale: The Stetler Model of Evidence-Based Practice culminates with an evaluation of the change in practice. Dissemination is not prescribed in the model and implementation does not form the "end point" of the implementation process.
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T/F: Evidence-based clinical decision-making considers the constraints of a patient's geographic location while a research utilization (RU) model does not address this parameter.
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True Rationale: Evidence-based clinical decision-making takes into account patient variables such as setting. RU is a more simplistic paradigm that solely encompasses the findings of research.
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A rating scale asks patients to gauge their nausea by describing it as "no nausea," "slightly nauseous," "significantly nauseous," or "severely nauseous." This scale provides the nurse with data at what level? A. Nominal B. Ordinal C. Interval D. Ratio
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B. Ordinal Rationale: Likert-type scales like the one presented provide ordinal level data. Phenomena are scaled in an ascending manner, but it is not possible to extrapolate insights from the data mathematically.
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Which of the following would be the best source for measuring the outcomes related to a proposed change in the skills mix in the nursing care at a hospital? A. Finance B. Human resources C. Quality management D. Administration
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B. Human resources Rationale: Human resource departments are a key source of data surrounding skills mix, staffing levels, staff demographics, recruitment, and retention. Departments such as finance, administration, and quality management would be less likely to provide data on the current skills mix at the hospital.
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T/F: The Health Outcomes Institute's Outcomes Management Model provides a four-step process for the critical appraisal of evidence.
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False Rationale: The Health Outcomes Institute's Outcomes Management Model delineates a process that can be used to guide measurement of the impact of new interventions on improving healthcare outcomes. It does not provide a specific process for critical appraisal of the literature.
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Which of the following evaluation indicators can be quantified and statistically analyzed? A. Environmental changes B. Professional expertise C. Outcome measures D. Patient-centered quality care
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C. Outcome measures Rationale: Outcome measures are quantifiable healthcare results, such as health status, death, disability, iatrogenic effects of treatment, health behaviors, and the economic impact of therapy and illness management. Environmental changes, professional expertise, and patient-centered quality care are measures that equally important, but which are more qualitative in nature.
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What is the most effective strategy for engaging care providers in a proposed EBP change? A. Disseminate the evidence that underlies the change B. Remind staff of their obligation to provide optimal care C. Bring in EBP experts to speak to staff members D. Organize discussions and meetings with EBP mentors
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D. Organize discussions and meetings with EBP mentors Rationale: Interactive discussions between EBP mentors and care providers are an effective way to increase knowledge and address attitudinal barriers. Other strategies, such as bringing in outsiders to teach, disseminating research findings, or telling caregivers that they are obliged to change, are less likely to engage them and foster genuine change.
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T/F: Implementation of EBP is the responsibility of graduate-prepared nurses and members of the nursing leadership.
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False Rationale: Implementation of EBP in the clinical setting is dependent on broad engagement and participation from all care providers at all levels, as well as leaders, administrators, and members of other disciplines.
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Which of the following factors has the greatest bearing on the success or failure of CPG implementation? A. The strength of the evidence that underlies the guideline B. The validity of the process that was used to develop the guideline C. The education level of the nurses who will implement the guideline D. The commitment of the caregivers who will put the guideline into practice
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D. The commitment of the caregivers who will put the guideline into practice Rationale: While CPGs must be based on strong evidence and must be developed in a valid manner, these factors do not determine the success of their clinical implementation. Successful implementation is dependent on the commitment of practitioners to the process. Education level is not a key determinant of success.
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T/F: A valid, reliable, and applicable clinical practice guideline becomes a permanent component of the healthcare literature.
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False Rationale: Because a body of evidence is constantly growing and changing, CPGs cannot be considered static documents. Regular reviews and changes are necessary.
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Which of the following online databases is the most likely source of a CPG to guide a nurse's care? A. CINAHL B. EBSCO C. PubMed D. PsycInfo
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C. PubMed Rationale: PubMed can be searched for CPGs by setting publication limits on the query to "practice guideline."
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T/F: EBPGs are a valid guide to practice because they encompass not only research evidence, but also patient preferences and clinical expertise.
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False Rationale: EBPGs are based on the best available evidence, but it is the responsibility of the individual clinician to integrate patient preferences and clinical expertise into consideration when planning care.
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A nurse has examined whether the participants in a qualitative study on the meaning of dependence among IV drug users are similar to the clients that the nurse works with. This nurse has evaluated this study's: A. Dependability B. Confirmability C. Transferability D. Credibility
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C. Transferability Rationale: Transferability addresses the question of whether the findings of a qualitative study are applicable to other people who are in similar situations.
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T/F: Grounded theory is the most appropriate tradition for a study that explores women's coping as they move through different stages of fertility treatment.
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True Rationale: Grounded theory often focuses on changes in the human experience as they move through time.
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Qualitative evidence is most likely to inform which of the following aspects of the care of patients with cancer? A. Cancer patients' perceptions of hope during chemotherapy treatment B. Treatment options for chemotherapy-induced nausea C. Clinicians' choices of chemotherapeutic agents D. The relationship between anxiety and nausea in patients undergoing chemotherapy
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A. Cancer patients' perceptions of hope during chemotherapy treatment Rationale: The concept of hope is an aspect of the human responses and meaning that surround a health experience. Treatment options and the relationships between different concepts are likely better addressed by quantitative evidence.
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T/F: Meta-analysis results in evidence that is applicable to a larger patient population than individual studies.
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False Rationale: In meta-analyses, combining the results of several studies produces a larger sample size and thus greater power to accurately determine the magnitude of the effect. This does not, however, increase the size of the relevant patient population.
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A team of researchers have received a grant to investigate the potential links between diet and the development of stomach cancer. What methodology is most likely to answer the researchers' clinical question? A. Case control B. Case study C. Randomized controlled trial (RCT) D. Qualitative study
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A. Case control Rationale: A case control study often selects individuals with a particular disease (e.g., stomach cancer) and looks back to identify factors that may underlie that disease (e.g., diet). Neither a case study nor a qualitative study would inform this relationship and an RCT would be unethical and impractical.
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T/F: The smaller the p value, the less likely the null hypothesis is true.
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True
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The findings of a quantitative study testing a high school-based sexual health program reveal that for every 140 female students who take the program, one pregnancy is prevented. This conclusion indicates the: A. OR B. NNT C. NNH D. ARR
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B. NNT Rationale: The number needed to treat (NNT) represents the number of people who would need to receive the therapy or intervention (the educational program) to prevent one bad outcome (teenage pregnancy).
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T/F: The best way to prevent selection bias is to randomly assign study participants to groups.
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True Rationale: Selection bias in quantitative studies is best controlled by assigning participants to groups on a random basis. Other systematic and deliberate methods of assignment normally increase the chance of selection bias.
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T/F: Internal evidence is characterized by findings that are applicable and generalizable to multiple practice settings.
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False Rationale: Unlike external evidence, the generation of internal evidence is intended to improve clinical practice and patient outcomes within the local setting that it is conducted.
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T/F: Internal evidence is characterized by findings that are applicable and generalizable to multiple practice settings.
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False Rationale: Unlike external evidence, the generation of internal evidence is intended to improve clinical practice and patient outcomes within the local setting that it is conducted.
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T/F: A post-‐operative patient's statement that Dilaudid (hydromorphone) has been ineffective in treating her pain can be considered a form of evidence.
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True Rationale: Patient preferences and experiences are an important consideration and are a form of evidence. While the patient's preference does not likely constitute the "final word" on treatment choices, it must be weighed carefully and integrated into the nurse' choice of intervention.
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Which of the following sources of knowledge would a nurse prioritize when determining the turning schedule for an immobilized patient? A. The traditional practice on the unit B. The nurse's knowledge of skin breakdown C. The preferences of the patient and the patient's family D. A clinical practice guideline for preventing skin breakdown
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D. A clinical practice guideline for preventing skin breakdown Rationale: EBP encompasses patient preferences and the clinical expertise of individual practitioners, but the primary source of knowledge is research evidence. Clinical practice guidelines synthesize this evidence in order to guide practice.
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Which of the following online evidence sources is most likely to provide pre-appraised evidence? A. CINAHL B. MEDLINE C. PubMed D. Cochrane Library
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D. Cochrane Library Rationale: The Cochrane Databases consist of systematic reviews that synthesize evidence from multiple peer-reviewed sources. CINAHL, MEDLINE, and PubMed may contain evidence at a synthesis level, but are more often sources of individual articles that a nurse must appraise.
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T/F: A controlled-vocabulary system may yield fewer hits than a keyword search, but these hits are more likely to be relevant to the clinical question.
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True Rationale: Controlled vocabulary systems exist to increase the relevance of search results while limiting the number of less-relevant hits.
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Which of the following sources of evidence is best able to inform a nurse's clinical practice? A. A well-designed randomized controlled trial (RCT) B. A systematic review that encompasses multiple studies C. Expert opinion of experienced and educated nurses D. A case study that addresses an unique clinical scenario
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B. A systematic review that encompasses multiple studies Rationale: Systematic reviews are considered to be higher on the hierarchy of evidence than expert opinion or individual RCTs and case studies.
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Which of the following components of a PICOT question is absent from this clinical question? "Among patients with dementia, how does use of reorientation therapy compared to regular, supervised mobility affect patient agitation?" A. P B. I C. O D. T
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D. T Rationale: This question specifies the patient population, the intervention, the comparison, and the relevant outcome, but does not provide a time frame.
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T/F: Foreground questions can often be answered by consulting an up-to-date nursing or science textbook
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False Rationale: Foreground questions are the frequently complex and specific clinical questions, which are answered by consulting rigorous evidence. This evidence is not typically available in textbooks, which are more appropriate for answering background questions.
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T/F: A well-formulated PICOT question should specify the patient outcome that the question will address.
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True Rationale: A PICOT question should specify the outcome that is expected from the clinical question.
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A group of nurses have successfully implemented a new, evidenced-base protocol around post-operative patient assessment. How should the nurses follow up this success? 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
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A. Tell others about the results of their project 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.
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An obstetrical nurse wants to implement EBP around the fetal monitoring practices on the unit. How should the nurse begin the EBP process? A. By reviewing the literature around the practice B. By consulting with expert nurses C. By fostering an attitude of curiosity D. By evaluating the outcomes of current practices
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C. By fostering an attitude of curiosity Rationale: Cultivating an attitude of inquisitiveness, curiosity, and inquiry is foundational to the EBP process and is considered to be "step 0." This should occur prior to reviewing the literature, seeking expert opinion, or critically evaluating the current practice on the unit.
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T/F: A rigorous randomized controlled trial (RCT) constitutes the highest level of evidence and the most reliable guide to nursing practice.
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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. A single RCT is classified at Level II evidence.
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T/F: Consulting a nursing journal article to determine the recommended turning frequency for immobile patients is an example of utilizing an external resource.
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True Rationale: External evidence includes publications that present the findings of rigorous research, and which are intended to be generalized to and used in other settings.
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Evidence Based Practice
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- A lifelong problem-solving approach to clinical practice that integrates: ~~ Search, critical appraisal, and synthesis of the most relevant and best research (*external evidence*, i.e. rigorous research) ~~ One's own clinical expertise, which includes *internal evidence* generated from practice initatives, such as outcomes management, quality improvement projects, patient assessment and evaluation. ~~ Patient preferences and values
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Steps of the EPB Process
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0. Cultivate a spirit of inquiry 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 practice decision or change. 5. Evaluate outcomes of the practice decision or change based on evidence. 6. Disseminate the outcomes of the EBP decision or change.
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Steps of the EPB Process 1. Ask the burning clinical question in PICOT format.
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*P* Patient population *I* Intervention or issue of interest *C* Comparison intervention or group *O* Outcome *T* Time frame
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Steps of the EPB Process 2: Search for and Collect the Most Relevant Best Evidence - Hierarchy of Evidence
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Level I: Systematic reviews or meta-analyses of RCTs Level II: RCTs Level III: Controlled trials without randomization Level IV: Case-control and cohort studies Level V: Systematic reviews of descriptive and qualitative studies Level VI: Single descriptive or qualitative studies Level VII: Opinion of authorities and/or reports of expert committees
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Steps of the EPB Process 3: Critically Appraise the Evidence
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Appraise: - Validity - Reliability - Applicability
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Steps of the EPB Process 4: Integrate the Best Evidence with Clinical Expertise and Patient Preferences
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- This is the "implementation" step - EBP is not based solely on research and published evidence - Patients' histories and circumstances have a significant bearing on the nurse's choice of intervention - Availability of resources must also be considered
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Steps of the EPB Process 5: Evaluate Outcomes of the Practice Decision or Change Based on Evidence
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- Measurement of outcomes is important to determine and document impact of the EBP change on healthcare quality and/or patient outcomes - Essential in determining whether the change based on evidence resulted in the expected outcomes when implemented in the real-world clinical practice setting
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Steps of the EPB Process 6: Disseminate the Outcomes of the EBP Decision or Change
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- Too often in healthcare, positive outcomes are not shared with others - There are numerous strategies for accomplishing this goal, from personal communication to conference presentation
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Background questions
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- Ask for general information about a clinical issue - Specify the staring point and the outcome of interest
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Foreground questions
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- Can be answered from scientific evidence about diagnosing, treating, or assisting patients with understanding their prognosis - Focus on specific knowledge - Types of Foreground questions: ~~ Intervention questions ~~ Prognosis/prediction questions ~~ Diagnosis questions ~~ Etiology questions ~~ Meaning questions
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Clinical Inquiry
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- An outcome of uncertainty - Defined as a process in which clinicians gather data together using narrowly defined clinical parameters to appraise the available choices of treatment for the purpose of finding the most appropriate choice of action
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External Sources of Evidence
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- textbooks and journals - consolidated resources
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Cochrane Databases (Library)
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- A collection of 6 different databases - *"Gold standard"* database is the Cochrane Database of Systematic Reviews (CDSR) - Systematic reviews are based on critical appraisal
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National Guideline Clearinghouse
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- A comprehensive database of evidence-based clinical practice guidelines - Guidelines are systematically developed statements about a plan of care for a specific set of clinical circumstances involving a particular population - Developed in partnership with the American Medical Association and the American Association of Health Plans - Of all the guidelines sources, the NGC contains the most descriptive information about guidelines Criteria for Inclusion of Clinical Practice Guidelines in NGC - All of the criteria below must be met for a clinical practice guideline to be included in NGC. - The clinical practice guideline contains systematically developed statements that include recommendations, strategies, or information that assists physicians and/or other health care practitioners and patients to make decisions about appropriate health care for specific clinical circumstances. - The clinical practice guideline was produced under the auspices of medical specialty associations; relevant professional societies, public or private organizations, government agencies at the Federal, State, or local level; or health care organizations or plans. A clinical practice guideline developed and issued by an individual not officially sponsored or supported by one of the above types of organizations does not meet the inclusion criteria for NGC. - Corroborating documentation can be produced and verified that a systematic literature search and review of existing scientific evidence published in peer reviewed journals was performed during the guideline development. A guideline is not excluded from NGC if corroborating documentation can be produced and verified detailing specific gaps in scientific evidence for some of the guideline's recommendations. - The full text guideline is available upon request in print or electronic format (for free or for a fee), in the English language. The guideline is current and the most recent version produced. Documented evidence can be produced or verified that the guideline was developed, reviewed, or revised within the last five years.
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MEDLINE
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- covers medicine, health, and the biomedical sciences
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CINAHL
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- covers 13 nursing and allied health disciplines
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EMBASE
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- major European biomedical and pharmaceutical database
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PsycInfo
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- covers psychology, behavioral sciences, and mental health
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Knowledge Sources for EBP
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1. Valid research evidence ---The primary basis of clinical decisions 2. Clinical expertise ---To best use research by filling in gaps and combining it with practice-based evidence to tailor clinical actions for individual patients' contexts 3. Patient choices and concerns ---For determining the acceptability of evidence-based care to the individual patient The main criterion is *certainty*
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The PDSA Cycle
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The PDSA Cycle Plan: Plan the change and observation Do: Try out the change on a small scale Study: Analyze the data and determine what was learned Act: Refine the change based on what was learned and repeat the testing
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Rating the Strength of a Body of Evidence Consistency:
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whether investigations with both similar and different study designs report similar findings (requires numerous studies)
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Rating the Strength of a Body of Evidence Quantity:
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the number of studies that have evaluated the question, overall sample size across all studies, magnitude of the treatment effect, strength from causality assessment, such as relative risk or odds ratio
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Rating the Strength of a Body of Evidence Quality:
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the extent to which a study's design, conduct, and analysis has minimized selection, measurement, and confounding biases (internal validity)
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Evidence
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- Research evidence - Clinical knowledge gained via the individual practitioner's experience - Patients' and practitioners' preferences - Basic principles from logic and theory
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Internal Evidence
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- Evidence that is generated by outcomes management, quality improvement, or EBP implementation projects - Aimed at improving outcomes at the site where improvement efforts are conducted Quality Indicator Systems: AHRQ National Healthcare Quality Report National Quality Forum (NQF) National Database of Nursing Quality Indicators® (NDNQI®)
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Quantitative approach to research
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- systematic - objective - deductive - generalisable - numbers - Cause & effect - Fixed data gathering - Uniform reporting style - Hypotheses guide research - Hierarchical
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Qualitative approach to research
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- systematic - subjective - inductive - not generalisable - words - Meaning, understanding - Use of open ended questions - Multiple reporting styles - No prior assumptions, acknowledge and suspend bias - nonhierarchical - Qualitative research is usually placed near the bottom of hierarchies of evidence
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Hypothesis
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a specific prediction regarding the answers to the research question
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Variable
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an attribute which varies and to which numbers or values are assigned
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Independent variable
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That which is manipulated by the investigator in an experiment
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Dependent variable
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a measurable outcome
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Control variable
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the process of holding constant confounding influences on the dependent variable
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Elements of research designs
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1. Intervention 2. Comparisons 3. Time a. Cross sectional or Longitudinal b. Retrospective or Prospective 4. Variables Univariate or Multivariate
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The Solomon four group test
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The Solomon four group test is a standard pretest-posttest two-group design and the posttest only control design. The various combinations of tested and untested groups with treatment and control groups allows the researcher to ensure that confounding variables and extraneous factors have not influenced the results. The main advantage to conducting an experimental study that employs a Solomon four group design (i.e., an experiment that uses a before-after design for the fi rst experimental and control groups and an after-only design for the second experimental and control groups; Polit & Beck, 2008) is that it can separate the effects of pretesting the subjects (i.e., gathering baseline measures) on the outcome measure(s) (see Figure 1 7.9). Disadvantages include the addition of subjects as well as costs for increasing the size of the sample.
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Factorial Designs
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Whenever we are interested in examining treatment variations, factorial designs should be strong candidates as the designs of choice. Second, factorial designs are efficient. Instead of conducting a series of independent studies we are effectively able to combine these studies into one. Finally, factorial designs are the only effective way to examine interaction effects.
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Time Series Design
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You make a few observations to establish a baseline, do the intervention, and then make a few more measurements. (Just how many observations you make on either side of the intervention is determined by the stability of the data. This will be covered in advanced concepts.) The major threat to the internal validity of the time series is history. That is, a charge that the results obtained would have occured with or without the experimental intervention is difficult to defend with data from the simple Time Series experiment.
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Quasi Experimental Design
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- Social scientific term Many different designs support conduct of a quasi-experiment. Broadly, these designs can include the simple quasi-experiment that mirrors the true experiment, but they typically do not use random assignment or a comparison group. In addition, quasi-experiments use less stringent control methods. Examples include the repeated measures quasi-experiment, in which subjects serve as their own controls and spend time receiving both the traditional practice and the new intervention, and the pretest/posttest quasi-experiment, which typically uses different groups of patients at different times. (See Chapter 17 for fi gures of quasi-experimental designs.) The Health Outcomes Institute's OM Model could be used to demonstrate this design, with the pretest measurement derived from use of the traditional practice at baseline (Phase 1), and the posttest measurement refl ecting adoption of the new intervention (Phase 3; Wojner, 2001).
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The "True" Experiment
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- Social scientific term The "true" experiment is considered the most rigorous of all research designs. (See Chapter 17 for figures of different experimental designs.) While the sophistication of experiments can be built upon to encompass additional arms and methods, the basic structure is presented here. When considering measurement of the impact of a new intervention using an experimental design, the impracticality of this method must be weighed against the superior quality of the fi ndings that will be achieved. For example, random assignment is used in which subjects are randomly assigned to treatment groups based on probability (e.g., flipping a coin). In addition, stringent controls are implemented, and a comparison or attention placebo group is used to compare outcomes against the experimental treatment group, which may make conduct of the study within a reasonable time frame challenging unless the investigators have access to a large sample of patients. Often use of a well-controlled, quasi-experimental approach provides a sound and more practical approach to the measurement of the impact of a new intervention compared to traditional practice (Wojner, 2001). See Chapter 17 for a more detailed discussion of various experimental designs.
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Nonexperimental study; correlational study
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- Social scientific term
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Retrospective Study
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- Social scientific term
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Prospective nonexperimental study
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- Social scientific term
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Randomized Control Trial
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- A Medical Research Term An RCT is defined as having three key elements: (a) an intervention or treatment group that receives the intervention, (b) a comparison group that has a comparison intervention, and (c) random assignment to either group (i.e., assignment of patients to either the experimental or comparison group by using chance, such as a flip of a coin). The groups are evaluated on whether or not an expected outcome is achieved. Randomized controlled trials are the most appropriate research design to answer questions of efficacy and effectiveness of interventions because their methodology provides confi dence in establishing cause and effect (i.e., increased confi dence that a given intervention leads to a particular outcome). As individual studies, RCTs rank as Level II evidence in the hierarchy of evidence because a well-conducted study should have a low risk of bias. A synthesis of RCTs is considered Level I evidence for answering questions about interventions for the same reason (see Chapter 1, Box 1.2). An RCT compares the effectiveness of different interventions. This can involve one treatment group getting the intervention under investigation and a comparison treatment group receiving another intervention (e.g., current standard of care for the same outcome) to determine which is better at producing the outcome. The interventions studied could be the experimental treatment compared to a comparison group, with the comparison group receiving no intervention (i.e., true control group), a placebo, or the usual standard of care. Randomized controlled trials are experimental studies in which participants are randomly assigned to each intervention in what are often referred to as the "arms" of a study. An RCT often has two arms, but may have more than two, such as when an intervention is being compared with no intervention and with a placebo. Randomized controlled trials also are prospective and longitudinal in that participants are studied over a period of time to assess the effects of an intervention or treatment on selected outcomes.
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Controlled trial, controlled trial without randomization
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- A Medical Research Term
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Observational study
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- A Medical Research Term
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Case-control study
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- A Medical Research Term Case-Control Studies. Case-control studies are those in which one group of individuals (i.e., cases) with a certain condition (e.g., migraine headaches) is studied at the same time as another group of individuals who do not have the condition (i.e., controls) to determine an association between one or more predictor variables (e.g., family history of migraine headaches, consumption of red wine) and the condition (i.e., migraine headaches). Case-control studies are usually retrospective, or ex post facto (i.e., they look back in time to reveal predictor variables that might explain why the cases contracted the disease or problem and the controls did not). Advantages of this type of research design include an ability to determine associations with a small number of subjects, which is especially useful in the study of rare types of diseases, and an ability to generate hypotheses for future studies (Newman, Browner, Cummings, et al., 2001 ). One of the major limitations to using this study design is bias (i.e., an inability to control confounding variables that may infl uence the outcome). For example, the two groups of individuals previously presented (i.e., those with migraines and those without migraines) may be different on certain variables (e.g., amount of sleep and stress) that also may influence the development of migraine headaches. Another limitation is that because case-control studies are usually retrospective, one is limited to data available at a prior time. Often, data on interesting variables were not thought to be important and not collected.
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Cohort
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- A Medical Research Term The cohort study design is especially suitable for investigating the course of a disease or the unintended consequences of a treatment (Fineout-Overholt & Melnyk, 2007; Guyatt et al., 2008). A cohort refers to a study population sharing a characteristic or group of characteristics. There are two ways to conduct a cohort study, with and without a control group. Case-Control Studies. Case-control studies are those in which one group of individuals (i.e., cases) with a certain condition (e.g., migraine headaches) is studied at the same time as another group of individuals who do not have the condition (i.e., controls) to determine an association between one or more predictor variables (e.g., family history of migraine headaches, consumption of red wine) and the condition (i.e., migraine headaches). Case-control studies are usually retrospective, or ex post facto (i.e., they look back in time to reveal predictor variables that might explain why the cases contracted the disease or problem and the controls did not). Advantages of this type of research design include an ability to determine associations with a small number of subjects, which is especially useful in the study of rare types of diseases, and an ability to generate hypotheses for future studies (Newman, Browner, Cummings, et al., 2001). One of the major limitations to using this study design is bias (i.e., an inability to control confounding variables that may infl uence the outcome). For example, the two groups of individuals previously presented (i.e., those with migraines and those without migraines) may be different on certain variables (e.g., amount of sleep and stress) that also may influence the development of migraine headaches. Another limitation is that because case-control studies are usually retrospective, one is limited to data available at a prior time. Often, data on nteresting variables were not thought to be important and not collected.
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Arm (e.g., intervention or control arm)
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- A Medical Research Term
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Bias
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anything that distorts study findings in a systematic way and arises from the study methodology - Selection bias - Knowledge of who is or is not receiving an intervention - Measurement bias - Recall bias - Contamination
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Confounded Study Results
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- A study's results may be confounded when a relationship between two variables is actually due to a third, either known or unknown variable - Often encountered in studies about lifestyle and health - Frequently a result of participant history
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Reliability Strength of association
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- Absolute risk reduction (ARR) - Absolute risk increase (ARI) - Relative risk (RR) - Relative risk reduction (RRR) - Odds ratio (OR) - Number needed to treat/harm (NNT/NNH)
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Random error
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- Variations that occur purely by chance - The extent to which random error may influence a measurement can be reported using statistical significance (or p values) or by confidence intervals.
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Confidence interval
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describes the range in which the true effect lies with a given degree of certainty
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Ethnography
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the study of a social group's culture through combining participant observation, in-depth interviews, and the collection of artifacts Useful for elucidating - People's experiences of health/illness - Issues of concern to caregivers - Individuals' experiences in certain types of settings
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Grounded theory
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- Purpose is to generate theory about how people deal with life situations that is "grounded" in empirical data - Movement through time is often expressed in terms of stages or phases
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Phenomenology
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the study of essences (meaning structures) intuited or grasped through descriptions of lived experience
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Hermeneutics
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viewing human "lived experience" as a text that is to be understood through the interpreter's dialogical engagement
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Credibility
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- Demonstrated by accuracy and validity that is assured through documentation - Roughly parallel to internal validity in quantitative appraisal
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Transferability
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- Demonstrated by information that is sufficient for a research consumer to determine whether findings are meaningful to other people in similar situations - Parallels external validity
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Dependability
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- Demonstrated by a research process that is carefully documented to provide evidence of how conclusions were reached and whether, under similar conditions, a researcher might expect to obtain similar findings - Parallels reliability
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Confirmability
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- Demonstrated by providing substantiation that findings and interpretations are grounded in the data - Parallels objectivity
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Inductive Reasoning
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developing generalizations from specific observations
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Deductive reasoning
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developing specific predictions from general principles
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Paradigm
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A world view; a general perspective on the complexities of the real world, with certain assumptions about reality
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Positivist paradigm
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- Reality exists; there is a real world driven by natural causes. - The inquirer is independent of those being studied - Values are held in check; objectivity is sought
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Naturalistic paradigm
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- Reality is multiple and subjective, constructed by individuals. - The inquirer interacts with those being studied; findings reflect the interaction - Subjective values are inevitable, desirable
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Clinical Practice Guidelines (CPGs)
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- Systematically developed statements based on the best available evidence - Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. [Institute of Medicine. (1990). Clinical Practice Guidelines: Directions for a New Program, M.J. Field and K.N. Lohr (eds.) Washington, DC: National Academy Press. page 38]. - CPGs address regional differences in the diagnosis, treatment, and management of patients - Accessing and synthesizing individual pieces of evidence can be time-consuming and overwhelming - CPGs are a time-effective and accessible source of evidence to guide practice - CPGs make finite recommendations for practice while still allowing the flexibility for situation-specific considerations - Evidence-based practice guidelines (EBPGs) can help bridge the gap between published scientific evidence and clinical decision making - However, the rigor of guidelines varies significantly
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National Library of Medicine (NLM) Gateway
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- Allows users to put in a search term that is then sent out to eight different NLM databases - Health Services/Health Technology Assessment Text (HSTAT) - Takes large guidelines, systematic reviews, and technology assessments and enables their texts to be searchable on the Internet
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AGREE II
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The AGREE II consists of 23 key items organized within 6 domains followed by 2 global rating items ("Overall Assessment"). Each domain captures a unique dimension of guideline quality.
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Outcomes Management (OM)
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A technology of patient experience designed to help patients, payers, and providers make rational medical care-related choices based on better insight into the effect of these choices on patient life
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Levels of Data: Nominal
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descriptive, low-level data. Data measured at the nominal level are the least sophisticated and lowest form of measurement. Nominal measurement scales assign numbers to unique categories of data, but these numbers have no meaning other than to label a group. Scales that describe the quality of a symptom by some descriptive format are nominal. For example, a nominal measure of the quality of pain may include such categories as "throbbing," "stabbing," "continuous," "intermittent," "burning," "dull," "sharp," "aching," "stinging," or "burning" (McHugh, 2003).
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Levels of Data: Ordinal
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ranking data from lowest to highest. Ordinal measures use categorical data as well. Numbers assigned to categories in ordinal measures enable ranking from lowest to highest so that the magnitude of the variable can be captured. However, it is important to note that while numbers are assigned to enable sorting of findings by rank, the absolute difference in each level on an ordinal scale does not possess an equal or "true" mathematical difference in the values. Likert scales provide clinicians with ordinal level data using selections such as "very dissatisfied," "dissatisfied," "neither dissatisfied nor satisfied," "satisfied," and "very satisfied." Clearly, each progression from very dissatisfied to very satisfied describes a greater level of satisfaction, but "very satisfied" could not be described as four times more satisfi ed than "very dissatisfied." When developing instruments, researchers typically use four or five categories from which to rank the variable of interest on a Likert scale.
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Levels of Data: Interval
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numeric values with fixed values separating each point. Interval measures are the next highest level of measurement and are purely derived from numeric data with equal and consistent mathematical values separating each discreet measurement point. While ratio level data possess this same characteristic, the difference between these two levels of measurement is that interval data do not possess an absolute zero point. The best examples of interval level data are temperature measures derived from the Fahrenheit scale which assigns 32° instead of zero as the point where water freezes.
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Levels of Data: Ratio
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similar to interval level, but with a true zero point. Interval measures are the next highest level of measurement and are purely derived from numeric data with equal and consistent mathematical values separating each discreet measurement point. While ratio level data possess this same characteristic, the difference between these two levels of measurement is that interval data do not possess an absolute zero point. The best examples of interval level data are temperature measures derived from the Fahrenheit scale which assigns 32° instead of zero as the point where water freezes.
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Research Utilization (RU) to EBP
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EBP is broader than research utilization because the clinician is encouraged to consider a number of dimensions in clinical decision making, one of which is evidence - Internal evidence - Patient preferences, setting, and circumstances - Clinical expertise - Available resources
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The Stetler Model of Evidence-Based Practice
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- Well-known as a practitioner-oriented model - Considers both internal and external evidence Phases or stages 1. Preparation 2. Validation 3. Evaluation 4. Translation/application 5. Comparative evaluation/decision making - Use of the model requires an RU/EBP competent individual - Such individuals also can informally use the model's critical-thinking process in their routine practice - Research findings and other credible evidence, such as consensus guidelines, may be used in multiple ways - Research findings and related evidence can be used symbolically (i.e., strategically) to influence the thinking and behavior of others
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Iowa Model of Evidence-Based Practice to Promote Quality Care
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- Provides guidance for nurses and other clinicians in making decisions about day-to-day practices that affect patient outcomes - A pragmatic multiphase change process with feedback loops - Widely recognized for its applicability and ease of use by multidisciplinary healthcare teams - Begins with practice questions or "triggers" - A team is formed to develop, implement, and evaluate the - practice change - The team selects, reviews, critiques, and synthesizes available research evidence - A practice change is piloted - A determination is made regarding appropriateness of adoption beyond the pilot - On-going evaluation - Dissemination
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The Model for Evidence-Based Practice Change
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A revised version of the model by Rosswurm and Larrabee (1999) Steps: 1. Assess the Need for Change in Practice 2. Locate the Best Evidence 3. Critically Analyze the Evidence 4. Design Practice Change 5. Implement and Evaluate Change in Practice 6. Integrate and Maintain Change in Practice
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The Advancing Research and Clinical Practice Through Close Collaboration Model (ARCC Model)
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- Exists to provide healthcare institutions and clinical settings with an organized conceptual framework that can guide system-wide implementation and sustainability of EBP to achieve quality outcomes - Developed out of nurse input as well as Control Theory and Cognitive Behavioral Theory - Contends that when clinicians' beliefs about the value of EBP and their ability to implement it are strengthened, there will be greater implementation of evidence-based care - EBP mentors play a central role - Workshops and academic offerings are available that develop these mentors - Barriers and facilitators to EBP, along with clinicians' beliefs about and actual implementation of EBP, can be readily assessed and identified by organizations using established instruments
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Promoting Action on Research Implementation in Health Services Framework (PARIHS)
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- Developed in an attempt to reflect the complexities of bringing evidence to practice - Successful implementation (SI) is represented as a function (f) of the nature and type of evidence (e), the qualities of the context (c) in which the evidence is being introduced, and the way the process is facilitated (f) Elements - Evidence - Context - Facilitation
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The Clinical Scholar Model
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- Developed to promote the spirit of inquiry, educate direct care providers, and guide a mentorship program for EBP and the conduct of research at the point of care - Clinical scholars are described as individuals with a high degree of curiosity that possess advanced critical-thinking skills and continuously seek new knowledge through continuous learning opportunities - Clinical scholar mentors play a central role - The Clinical Scholar Program was developed to actualize the Clinical Scholar Model - Observe and reflect - Critique and analyze - Synthesize - Apply and evaluate - Disseminate
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The Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP)
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- Facilitates bedside nurses in translating evidence to clinical, administrative, and educational nursing practice - Sets a goal to build a culture of nursing practice based on evidence - Aims to demystify the EBP process for bedside nurses and embed EBP into the fabric of nursing practice - *P* Practice Question - *E* Evidence - *T* Translation
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SMART Goals
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*S* Specific *M* Measurable *A* Attainable *R* Relevant *T* Time Bound
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SCOT Analysis
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*S* Strengths - Identify the current strengths in the system that will facilitate the success of a new project. *C* Challenges - Identify the challenges in the system that may hinder the initiative. *O* Opportunities - Outline the opportunities for success. *T* Threats - Delineate the threats or barriers to the project's completion, with strategies to overcome them.
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Organizational Change Models: The Change Curve Model
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Provides basic assumptions for change in an organization Stages I: Stagnation II: Preparation III: Implementation IV: Determination V: Fruition
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Organizational Change Models: Kotter and Cohen's Model of Change
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Proposes that the key to change is appealing to emotion Step 1: Increase a sense of urgency Step 2: Build the guiding team Step 3: Get the vision right Step 4: Communicate for "buy-in" Step 5: Empower action and remove barriers Step 6: Create short-term wins Step 7: Don't let up Step 8: Make the change stick
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Organizational Change Models: Diffusion of Innovations
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Preparation Phase: - Contact - Awareness Acceptance Phase: - Understanding - Positive Perception Commitment Phase: - Adoption - Institutionalisation
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Organizational Change Models: The Transtheoretical Model of Health Behavior Change
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- Conceptualized to explain patients' change, but also applicable to organizational change Stages: - Precontemplation - Contemplation - Preparation - Action - Maintenance The goal is to help individuals move along the continuum
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Rohm's taxonomy (the DISC Model)
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Any time that change is introduced in a system, it is important to be sensitive to the personality styles of individuals Rohm's taxonomy (the DISC Model) *D* Personality Styles: Drivers *I* Personality Styles: Inspired *S* Personality Styles: Supportive and Steady *C* Personality Styles: Contemplators
