Chapter 21

Translating Research into Practice

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc.

Learning Outcomes

Value the individual nurse’s obligation to use research in practice.

Analyze the differences among evidence-based practice, and practice-based evidence, comparative effectiveness, and outcomes research.

Formulate a clinical question that can be searched in the literature.

Evaluate resources for the best available evidence.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 2

Learning Outcomes (Cont.)

Identify resources for critically appraising evidence.

Assess organizational barriers to and facilitators of the implementation of research findings.

Identify strategies for translating research into practice within the context of an organization.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 3

Societal Factors Influencing the Use of Research

Rising cost of health care Quality improvement initiatives Pressures to avoid errors Research about the costs of not

implementing evidence Publicity about research findings

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 4

Research

“Diligent, systematic inquiry or investigation to validate and refine existing knowledge and generate new knowledge” (Burns & Grove, 2013, p. 1)

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 5

Support for the Significance of Research in Practice

Nursing’s Social Policy Statement. (American Nurses Association [ANA], 2010).

Code of Ethics for Nurses. (ANA, 2001). Nursing: Scope and Standards of Practice.

(ANA, 2010). Nursing Research [Position Statement].

(International Council of Nurses, 2007)

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 6

Expectations for Professionals

Knowing where and how to find the best possible sources of evidence

Formulating clear clinical questions Searching for relevant answers from the best

possible sources Determine when and how to integrate findings

into practice (Greiner & Knebel, 2003)

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 7

Types of Research Use

Enlightenment Implementation of a research-based protocol Widespread adoption of standards based on

research findings

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 8

Speaking of Research

Basic vs. applied Qualitative vs. quantitative Cross-sectional vs. longitudinal Descriptive vs. experimental Retrospective vs. prospective

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 9

Research Application

Some research is ready for application. Some research is not yet ready for

application. Readiness for application is not necessarily

dependent on the research design. A single study may provide sufficient

evidence for implementation.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 10

National Institutes of Health Roadmap

New pathways to discovery New strategies for diagnosing, treating, and

preventing disease Research teams of the future

Interdisciplinary teams, public-private partnerships Reengineering the clinical research

enterprise Clinical research networks, policy analysis and

coordination, chronic disease outcomes, translational research

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 11

American Recovery and Reinvestment Act of 2009

Set aside $1.1 billion for comparative effectiveness research

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 12

Research Utilization

Use of knowledge from research to make a change in practice Example:

• Reading a research report on how to most effectively teach new mothers how to breast-feed

• Applying research results to the clinical setting

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 13

Evidence-Based Practice (EBP)

Evidence-based medicine: integration of best research evidence with clinical expertise and the patient’s unique values and circumstances in making decisions about the care of individual patients. (Straus et al., 2011)

Use of evidence-based practice denotes use of evidence by all healthcare practitioners.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 14

Evidence-Based Practice (EBP) (Cont.)

Searching for the best research-based answer to a clinical practice problem Example:

• New mothers are not breast-feeding even after receiving instruction.

• Research-based protocol is developed based on the best scientific evidence about teaching breast-feeding.

Includes consideration of patients’ preferences

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 15

Selected Practice Improvement Arenas

Preoperative teaching Pain management Assessment of children’s behavior Prevention of falls Pressure ulcer risk detection Incontinence care Family-centered care in intensive care

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 16

Translation of Research into Practice (TRIP)

The science of how research is best translated into practice Example:

• The best strategies for getting staff members to use a new evidence-based protocol for teaching new mothers about breast-feeding

Also known as translation science

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 17

Comparative Effectiveness Research

“Generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care.” (Institute of Medicine, 2009, p. 29)

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 18

Foundation for Comparative Effectiveness Research (CER)

Efficacy: testing an intervention or treatment in a traditional research study, such as a randomized clinical trial (RCT) under carefully controlled conditions

Effectiveness: testing whether an intervention works in the real world of practice with a focus on the decision needs of clinicians and patients

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 19

Asking the Right Question: PICO Format

Patient population Intervention/interest area Comparison Outcome

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 20

Practice-Based Evidence

A comparative effectiveness approach Research methodology that helps inform

practice decisions by examining outcomes in the real world, where patients may not be similar and the actual application of an intervention may have multiple variations

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 21

Participatory Action Research

Members of the community being studied are integral members of the research team and are involved in identifying the questions and addressing the issues involved in the implementation of the research project (Chevalier & Buckles, 2013)

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 22

Quality Improvement

Uses data to improve processes and outcomes of care (Shirey et al., 2011)

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 23

Nurse-Sensitive Outcomes

Outcomes directly related to the quality of nursing care Examples:

• Falls• Nosocomial infections such as urinary tract infections• Pressure ulcers

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 24

Patient-Centered Outcomes Research Institute (PCORI)

Created under auspices of the Centers for Medicare & Medicaid Services (CMS) by the Affordable Care Act (ACA) of 2010

Includes stakeholder input Focused on

Improving healthcare systems Communication and dissemination Addressing disparities Accelerating patient-centered outcomes research

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 25

Diffusion of Innovations: Stages

Knowledge Exposure to information

Persuasion Attitude development

Decision Commitment to adoption

Implementation Application to practice

Confirmation

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 26

Knowledge Stage

Information dissemination Journals Conferences Educational programs Media

Literature review

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 27

Persuasion Stage

Informal communication networks Use of a champion Attitudes may be positive or negative.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 28

Decision Stage

Commitment to adoption Innovation might be adopted. Innovation might be rejected.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 29

Implementation Stage

Direct application Exactly as it was done in previous research Exactly as recommended in a guideline

Reinvention Modified to suit the environment

Indirect application Modified according to the needs and values of the

staff

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 30

Confirmation Stage

Evaluating the innovation Make a decision

• Continue• Discontinue• Modify

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 31

Characteristics of Innovation Adopters

Innovators Early adopters Early majority Late majority Laggards

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 32

Stetler’s Research Utilization Model to Facilitate Evidence-Based Practice

Preparation Validation Evaluation/decision making Translation/application Evaluation

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 33

Steps in Evidence-Based Practice

Asking the relevant clinical question Searching for the best evidence Critically appraising evidence Integrating evidence with clinical expertise,

patient preferences, and values in making a practice decision or change

Evaluating the practice decision or change

From Melnyk, B.M., & Fineout-Overholt, E. (2005). Making the case for evidence-based practice. In B.M. Melynk, & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing and health care (p. 9). Philadelphia: Lippincott, Williams & Wilkins.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 34

Individual Strategies for EBP

Identify challenges in providing care. Ask questions about agency practices. Ask for the evidence underlying practices.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 35

Research Networks

Practice-based research networks (PBRNs) Electronic data-sharing consortia Veterans Administration (VA) Quality

Enhancement Research Initiative (QUERI) Magnet

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 36

Translating Research into Practice (TRIP)

“Scientific investigation of methods and variables that affect adoption of evidence-based healthcare practices by individual practitioners and healthcare systems to improve clinical and operational decision-making… … includes testing the effects of strategies to promote and sustain evidence-based practices.”

(Titler, 2004, p. 38)

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 37

Organizational Issues

Lack of resources Limited expertise of staff members Lack of knowledge about nursing research Limited time for planning

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 38

Organizational Strategies

Create partnerships between nurses and researchers

Involve key decision makers Understand organizational context Support a research culture Build capacity and infrastructure Formulate staff expectations recognition Provide technical support

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 39

Strategies for Nurse Leaders and Managers

Partnering with nurse researchers in academia

Collaborating with interdisciplinary team members

Joining practice-based research networks Establishing journal clubs Using nurses associations’ resources for

policy and research Publicizing successes

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 40