Module 1

Ways to adhere to ethical principles

 Risk / Benefit Assessment
 Informed Consent
 Confidentiality Practices
 External Review
 Vulnerable Groups

Vulnerable groups
 May be incapable of giving informed consent
 May be at high risk for unintended side effects of the research

What is evidence-based practice (EBP)?

 Quality improvement (QI) – improve processes with a particular setting
o NOT human research = does not require IRB (ethics)
 Research – generate new knowledge
 Evidence-based practice (EBP) – apply existing knowledge
o Best evidence
 Stay UTD with evidence
o Clinical expertise
o Patient values and preferences
o Clinical setting

Evidence categories (2)

 Pre-appraised evidence – not a single study
o Systematic reviews *Cochran is best
 Meta-analysis: Taking data and analyzing together
 Need similar data
 Meta-synthesis: Qualitative
o Clinical practice guidelines: Gather data about a clinical question; Generalized
 Primary studies – Individual studies

Hierarchy of evidence
Models for EBP – don’t need to memorize
 The ACE Star Model of Knowledge Transformation
 The Advancing Research and Clinical Practice through Close Collaboration Model
(ARCC Model)
 The Iowa Model of EBP
 Joanna Briggs Institute Model of Evidence Based Healthcare
 The Johns Hopkins Nursing Evidence-based Model
 The Knowledge-to-Action Cycle
 The Promoting Action on Research Implementation in Health Sciences (PARIHS)
Framework
 The Rosswurm and Larrabee Model to Change Clinical Practice
 The Stetler Organizational Framework for EBP

Steps of the EBP process

1. Ask a clinically meaningful question
o PICOT
 Acronym:
 Patient population
 Intervention, issue of interest
 Comparison
 Outcome
 Time (optional)
 Types:
 Therapy/Treatment/Intervention
 Diagnosis/Assessment
 Prognosis
 Etiology/Harm
Description (prevalence/incidence)
Meaning/Process: what motivates pts?
2. Collect the evidence via search
o PICOT question will define your keywords
o Select databases you’ll search:
 CINAHL
 PubMed
 Cochrane Database of Systematic Reviews
o Select limits to place on your search
o Conduct the search and keep track of your results
 Table

o Apply a systematic way to review your hits and select articles

 Where you searched
 What keywords you used
 What limits you placed on the search
 Number of hits
3. Critically appraise the evidence
o Level & quality
4. Synthesize the evidence
5. Integrate evidence with clinical expertise, patient values/preferences, and clinical setting
6. Make a decision and implement
7. Evaluate outcomes

Research overview
 Problem Statement
o Problem identification
o Background
o Scope
o Consequences of the problem/Significance
o Knowledge gap
o The purpose of this study was to…. investigate, test, evaluate, compare, examine,
explore, describe, understand, discover
 Research Question
o In (population), what is the relationship between (IV) and (DV)?
o In (population), what is the effect of (IV) on (DV)?
o What is the frequency of (V) among (population)?
o What is the lived experience of…?
 Hypotheses include population, variables, relationship
o Variables:
 Independent
 Dependent: Will be affected by intervention
 Conceptual definition
 Operational definition: Numbers
 o Relationship:
 Directional research hypotheses:
 Nurses who work rotating shifts will report higher job satisfaction
compared to nurses who work only day shift and nurses who work
only night shift.
 Nondirectional research hypotheses
 Don’t know what the outcome is, but know there is a relationship
 There will be a difference in job satisfaction between nurses who
work only day shift, nurses who work only night shift, and nurses
who work rotating shifts.
 Corresponding null hypothesis: No differences
 There will be NO difference in job satisfaction between nurses
who work only day shift, nurses who work only night shift, and
nurses who work rotating shifts.

Research overview
 Methods:
o Quantitative vs Qualitative
 QuaNtitative: Does participation in a 6-week long behavioral intervention
affect teenagers’ test-taking anxiety?
 QuaLitative: What is the lived experience of taking the SAT for teenagers
with test-taking anxiety?
o Purpose of the study
 Identification
 Description
 Exploration
 Prediction and Control (usually quaNtitative)
 Explanation
 Quantitative Research:
o Experimental
o Quasi-experimental (no randomization)
o Nonexperimental
 Qualitative Research:
o Phenomenology (lived experience)
o Ethnography (world view, cultural experience)
o Grounded theory (generate a theory using data)

Literature synthesis project example

Background
Central line associated bloodstream infections (CLABSIs) often are preventable nosocomial
infections that can have profound effects on patient morbidity, mortality, length of stay, and
hospital costs (citations, year). In an effort to decrease the number of CLABSIs among patients
admitted to inpatient units, Hospital A introduced a new central line insertion bundle, a central
line maintenance bundle, and nursing guidelines around central venous catheter care. In these
bundles, 2% chlorhexidine (CHG) was identified as the only agent to be used when cleaning a
central line site during insertion and with dressing changes. Implementation of the bundles has
resulted in a decrease in CLABSIs.

In addition to using as a site cleanser, CHG is a product often used for entire body bathing
(citation, year). A question was raised about whether adding daily bathing with CHG would
continue the decrease in CLABSIs.

PICOT question
Among children with central lines (P), does receiving a daily bath with chlorhexidine (I), as
compared to receiving a daily bath with soap and water (C), affect rates of CLABSIs (O) during
an inpatient admission (t)?

Collect the evidence

Search Strategy:
 Databases: PubMed, CINAHL, Cochrane Database of Systematic Reviews
 Keywords: pediatrics, children, chlorhexidine bathing, central line associated
bloodstream infections, CLABSIs
 Limits & Filters: All dates considered; articles published in English only

Search Results:
Collect the evidence
Search Results:
 Titles of the 38 hits found using the keywords “chlorhexidine bathing” + “central line
associated bloodstream infection” were reviewed
 9 were excluded because they were duplicates, resulting in review of 29 abstracts
o 2 were excluded because they described studies in progress without results
o 15 were excluded because they did not measure and compare rates of CLABSIs
o 3 were excluded because they were descriptions of the same study
 This resulted in a total of 9 studies being included in the literature synthesis

The following 9 articles were used in the project:

Author, I.I., Author, I.I., & Author, I.I. (year). Article title with only the first letter of the first
word capitalized. Journal Title Capitalized and Italicized, volume, pages. DOI:

 Polit & Beck, Chapters 1-7

 Review the Study Guide for Essentials of Nursing Research materials for Chapters 1-7

Differences among EBP, QI, and Research:

Ceper, J. (2011). Differences among quality improvement, evidence-based practice, and
research. J Neurosci Nurs, 43, 230-232Links to an external site.
EBP Resources:
Explore these websites and articles that provide various EBP Resources
  Evidence-Based Practice: Step by Step series. This is an educational series to provide
information about evidence-based practice.
Click here to access step 1.Links to an external site.
Click here to access step 2.Links to an external site.
Click here to access step 3.Links to an external site.
Click here to access step 4.Links to an external site.
Click here to access step 5.Links to an external site.
Click here to access step 6.Links to an external site.
Click here to access step 7.Links to an external site.
Click here to access step 8.Links to an external site.
Click here to access step 9.Links to an external site.
Click here to access step 10.Links to an external site.
Click here to access step 11.Links to an external site.
Click here to access step 12.Links to an external site.
 Examples of practices that are frequently done but there is no evidence for these
practices: MakicLinks to an external site., M.B.F., VonRueden, K.T., Rauen, C.A., &
Chadwick, J. (2011). Evidence-based practice habits: Putting more sacred cows out to
pasture. Critical Care Nurse, 31, 38-61
 Example of an EBP project: Snyder, C.R.H. & Facchiano, L. (2011). An evidence-
based critical appraisal of a topic: Effectiveness of high dose donepezil for advanced
Alzheimer's disease. The Journal for Nurse Practitioners, 7, 201-206.Links to an
external site.
 Joanna Briggs Institute: “The Institute collaborates internationally with over 70
entities across the world. The Institute and its collaborating entities promote and
support the synthesis, transfer, and utilization of evidence through identifying
feasible, appropriate, meaningful, and effective healthcare practices to assist in the
improvement of healthcare outcomes globally.” http://joannabriggs.org/Links to an
external site.
 Implementation Science journal: “Implementation Science is an open access, peer-
reviewed online journal that aims to publish research relevant to the scientific study
of methods to promote the uptake of research findings into routine healthcare in
clinical, organizational or policy
contexts.” http://www.implementationscience.com/Links to an external site.
 Worldviews on Evidence-based Nursing journal: One of the most relevant EBP
journals for nursing
clinicians.http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787Links to an
external site.
 International Journal of Evidence-Based Healthcare
journal: http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1744-1609Links to an
external site.

Critical Appraisal Forms:

You will need to use a standardized system to assess the articles that you include in your
literature synthesis. The following websites provide several different examples of tools that can
be used to critically appraise research articles. Browse the different websites to determine which
tools make the most sense and would be the most useful to you to use for your literature
synthesis.
 Cincinnati Children’s Evidence Collaborative: Looks at the LEGEND Appraisal
Forms in the table near the bottom of the page. This website provides appraisal forms
to answer specific types of questions and related to the specific study design of the
article. They no longer offer their forms online. You can go to this link and request
them if you want to use this
system: http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-
care/legend/Links to an external site.
 Health Evidence Bulletins-
Wales: http://hebw.cf.ac.uk/projectmethod/appendix13.htmLinks to an external site.
 AGREE tool: This tool is used to appraise clinical practice
guidelines. https://www.agreetrust.org/resource-centre/Links to an external site.
 Explore the GRADE Working Group website. This group is working toward an
international standard grading system for critically appraising
evidence. http://www.gradeworkinggroup.org/Links to an external site.

EBP Models and Frameworks:

There are several different models to Evidence Based Practice. Below are resources to learn
more about several of the more commonly used EBP Models.
 Editorial on Using Theory and Frameworks to Facilitate the Implementation of
Evidence into Practice.Links to an external site.
 The ACE Star Model of Knowledge
Transformation: http://www.acestar.uthscsa.edu/acestar-model.aspLinks to an
external site.
 Click here Links to an external site.– Abbott, C.A., Dremsa, T., Stewart, D.W., Mark,
D.D., & Swift, C.C. (2006). Adoption of a ventiltor-associated pneumonia clinical
practice guideline. Worldviews Evid Based Nurs, 3, 139-152.
 The Advancing Research and Clinical Practice through Close Collaboration Model
(ARCC Model): http://books.google.com/books?
id=hHn7ESF1DJoC&lpg=PT195&ots=HjOyk7j-2_&dq=arcc%20model
%20evidence-based%20melnyk&pg=PT191#v=onepage&q=arcc%20model
%20evidence-based%20melnyk&f=falseLinks to an external site.
 The Iowa Model of EBP - http://hawaiicenterfornursing.org/aboutebpLinks to an
external site.Joanna Briggs Institute Model of Evidence Based
Healthcare: http://proxy.libraries.uc.edu/login?url=http://dx.doi.org/10.1111/j.1479-
6988.2005.00026.xLinks to an external site.
 Example of the use of the Iowa Model – Gordon (2008) How fast is too fast?
Advances in Neonatal Care, 8, 198-207.Links to an external site.
 The Johns Hopkins Nursing Evidence-Based Model – (Appendix C of the document
at this link provides a visual model): Click here for the John Hopkins guidelinesLinks
to an external site.
 The Knowledge-to-Action
Cycle: http://ktclearinghouse.ca/knowledgebase/knowledgetoactionLinks to an
external site.
  The Promoting Action on Research Implementation in Health Sciences (PARiHS)
Framework– http://dev.nccmt.ca/registry/view/eng/85.htmlLinks to an external site.
 The Rosswurm and Larrabee Model to Change Clinical Practice - A model for change
to evidence-based practice Rosswurm and Larrabee. Image J Nurs Sch 1999, 31, 317-
322.The Stetler Organizational Framework for EBP – Stetler, C.B. (2001). Updating
the Stetler Model of research utilization to facilitate evidence-based practice. Nursing
Outlook, 49, 272-279.Links to an external site.

Type of Questions & Hypotheses:

Review the Research Methods Knowledge Base page on Types of
Questionshttp://www.socialresearchmethods.net/kb/resques.phpLinks to an external site.
Trochim, William M. The Research Methods Knowledge Base, 2nd Edition.

Review the Research Methods Knowledge Base page

on Hypotheseshttp://www.socialresearchmethods.net/kb/hypothes.phpLinks to an external site.
Trochim, William M. The Research Methods Knowledge Base, 2nd Edition.

Research Ethics:
Review the Research Methods Knowledge Base page on Ethics in
Researchhttp://www.socialresearchmethods.net/kb/ethics.phpLinks to an external site.
Trochim, William M. The Research Methods Knowledge Base, 2nd Edition.