CANO 2010 - Research Workshop:

Moving Evidence into Practice

Dawn Stacey RN, PhD, CON(C), University of OttawaDenise Bryant-Lukosius, RN, PhD,CON(C), McMaster University, HamiltonAndrea Maria Laizner, RN, PhD, McGill University Health Center, Montreal

On behalf of Cancer Care Ontario’s Community of Practice Nursing Research Group and CANO Research Committee

Workshop Objectives Increase awareness of clinical practice guidelines (CPGs) as

an effective knowledge translation tool for promoting evidence-informed oncology nursing practice

Increase awareness/understanding of how to access, appraise and adapt CPGs

Identify implementation strategies for promoting the uptake of CPGs

Discuss the role of oncology nurses as knowledge brokers

Workshop Outline1. Welcome & introductions (~30 min)

2. Clinical Practice Guidelines – what, how to find them, appraising their quality (~30 min)

3. Strategies for implementing guidelines in clinical practice (~20 min)

4. Case study: implementation of guidelines in oncology nursing practice (~30 min)

5. Wrap-up and workshop evaluation (~10 min)

Introductions Name Place of work Objectives for this workshop Involvement in EINP and/or CPG activities

Introduction What is evidence informed nursing

practice (EINP)?

What is Evidence-Based Practice ?

“The integration of best research evidence with clinical expertise and patient values to facilitate clinical

decision making.” (Sackett et al., 2000)

Model of EBP (DiCenso, Ciliska, & Guyatt, 2005)

Clinical Expertise

Research Evidence Health Care Resources

Patient Preferences &

Actions

The Patient’s Clinical State, Setting & Circumstances

Steps of EINP Identify an answerable question

Search for the best information

Appraise the strength of the evidence

Make conclusions about the clinical relevance of the evidence

Apply all the information to practice & evaluate the outcome

CPGs and EINP Where do CPGs fit within the steps of

EINP?

Research to Practice Gap Delay in the uptake of high quality

research evidence into practice

Even when good evidence exists nurses and other health providers continue utilize sub-standard practices that contribute to patient harm, ineffective use of health care resources, and poor quality care

Research to Practice Gap What barriers and supports exist in your

practice environments that would influence implementation of guidelines in practice?

Barriers to EINP Attitude and beliefs Lack of time Limited access to the literature Lack of skills

Identifying answerable question Searching the literature Critical appraisal

Organizational culture

Assessing Barriers to EINP Awareness Acceptance Applicability Availability and feasibility Act on Agreed to Adhered to

Workshop Outline1. Welcome & introductions (~30 min)

2. Clinical Practice Guidelines – what, how to find them, appraising their quality (~30 min)

3. Strategies for implementing guidelines in clinical practice (~20 min)

4. Case study: implementation of guidelines in oncology nursing practice (~30 min)

5. Wrap-up and workshop evaluation (~10 min)

Knowledge Translation in Healthcare

Chapter 2.3Knowledge Translation Tools

Melissa C. Brouwers, PhDAssociate Professor and Lead of Health Services Research, Dept of Oncology

Associate Member, Dept. Of Clinical Epidemiology & Biostasticis, McMaster University

Dawn Stacey, RN, PhDAssociate Professor, School of Nursing, University of Ottawa

Associate Scientist, Ottawa Hospital Research Institute

Annette O’Connor, RN, PhD, FCAHSProfessor, School of Nursing, University of Ottawa

Senior Scientist, Ottawa Hospital Research Institute

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Know

ledg

e

MonitorMonitorKnowledgeKnowledge

UseUse

SustainSustainKnowledgeKnowledge

UseUse

EvaluateEvaluateOutcomesOutcomes

AdaptAdaptKnowledgeKnowledge

to Local Contextto Local Context

AssessAssessBarriers to Barriers to

Knowledge UseKnowledge Use

Select, Tailor,Select, Tailor,ImplementImplement

InterventionsInterventions

Identify ProblemIdentify Problem

Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge

Products/Products/ToolsTools

SynthesisSynthesis

Knowledge Knowledge InquiryInquiry

Tailo

ring

Know

ledg

e

KNOWLEDGE CREATIONKNOWLEDGE CREATION

(Graham et al: lost in KT. 2006}

KT ToolsKnowledge Tools

Clinical Practice Guidelines Patient Decision Aids

Used to assist clinicians and patients to make evidence-based decisions

Provide an explicit evidence-based description of the risk and benefits of an intervention

Outline where evidence is lacking

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Know

ledg

e

KT ToolsWhat are Clinical Practice Guidelines (CPGs)?

Systematically developed statements aimed to assist clinicians and patients in making decision about appropriate health care for specific clinical circumstances (Woolf et al., 1999).

Systematic vs. arbitraryAssist and not supplant decision making

Not formulaic protocols

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Know

ledg

e

KT Tools

CPGs – Essential Elements Establish multidisciplinary team Identify question Systematic review of evidence Appraise and interpret evidence Draft recommendations

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Know

ledg

e

KT Tools

CPGs – Essential Elements External review of draft Revise recommendations Dissemination Implementation

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Know

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KT Tools

CPGs – Do They Work?Systematic review by Grimshaw et al*

10% improvement in processes and outcomes of care

* J Gen Intern Med 2006 Feb;21 Suppl 2:S14-20 * Health Technol Assess 2004 Feb;8(6):iii-iv, 1-72

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Know

ledg

e

Finding CPGs relevant to Oncology Nursing

1. CPACC2. Cancer Journey3. COSTARS Project4. Oncology Nursing Society – PEP guidelines5. Cancer Care Ontario6. BC Cancer Agency7. National Comprehensive Cancer Network8. Registered Nurses Association of Ontario Best Practice Guidelines9. Johanna Briggs Institute 10. Other

CPGs – Determining Quality

AGREE Intstrument (www.agreetrust.org) International standard of guideline development,

reporting and evaluation Assesses the process of CPG development in 6

areas (23 items): Scope and purpose Stakeholder Involvement Clarity of Presentation Rigour of Development Applicability Editorial Independence

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Know

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AGREE Appraisal – Results on Cancer Treatment Induced Diarrhea Guidelines

AGREE DOMAIN 3: Rigour of Development

8. Systematic methods used to search evidence 9. Criteria for selecting evidence are clearly described10. Methods for formulating recommendations are clearly

described11. Health benefits, side effects and risks have been

considered in formulating recommendations

12. An explicit link between recommendations and supporting evidence.

13. Guideline was externally reviewed by an expert panel prior to publication

14. Procedure for updating the guideline is provided

CPGs – Determining Quality

GLIA (Guideline Implementability Appraisal)Tool * provides perspective by assessing extent to which

recommendations are implementable

*http://nutmeg.med.yale.edu/glia

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Know

ledg

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Exercise: Appraising Quality of a Guideline Tools:

AGREE checklist Example guideline

Workshop Outline1. Welcome & introductions (~30 min)

2. Clinical Practice Guidelines – what, how to find them, appraising their quality (~30 min)

3. Strategies for implementing guidelines in clinical practice (~20 min)

4. Case study: implementation of guidelines in oncology nursing practice (~30 min)

5. Wrap-up and workshop evaluation (~10 min)

CAN-Implement for guideline adaptationCAN-Implement for guideline adaptation

CAN-Implement for Guideline Adaptation

1. Call to action – motivation, purpose, scope2. Plan – identify health questions & select steering

committee/ working panel3. Search & screen - guidelines & SRs4. Assess & select

AGREE rating, currency, applicability, acceptability in local context

Achieve consensus on selecting recommendations1. Draft/Revise Recommendations – internal & external

review2. Plan Implementation

(Harrison et al. Quick Reference Guide Steps 1 to 6, Oct 09)

Nurses as Knowledge Brokers

• Serve as an intermediary to: facilitate researcher & knowledge user collaborations find evidence to shape decisions assess, interpret and adapt evidence to local context identify emerging issues that research can help solve

• Need leadership, marketing and communication skills with capacity to span boundaries & understand the potentially disparate worlds of researchers & knowledge users

• Have diverse experiences in these different worlds or organizations whose mandate it is to span these worlds

• Need to recognize & formalize this role & evaluate its effectiveness as a KT mechanism

(Gagnon, 2009 Chapter 5.1 KT in Healthcare; Dobbins M, Robeson P, Ciliska D, Hanne S, Cameron R, O’Mara L, DeCorby K, Mercer S. Implementation Science. 2009, 4:23)

Knowledge Brokers: Core Competencies

1. Develop mutual understanding of goals and cultures

2. Collaborate with knowledge users and producers to identify issues and problems for which solutions are required

3. Facilitate the identification, access, assessment, interpretation, and translation of evidence into policy and practice

4. Facilitate the management of information and knowledge

(Harris M and Lusk E. Knowledge Brokering in the Canadian Mental Health and Dementia Health Care System: Canadian Knowledge Brokering Core Competency Framework. Canadian Dementia Knowledge Translation Network. Canada; 2010)

Workshop Outline1. Welcome & introductions (~30 min)

2. Clinical Practice Guidelines – what, how to find them, appraising their quality (~30 min)

3. Strategies for implementing guidelines in clinical practice (~20 min)

4. Case study: implementation of guidelines in oncology nursing practice (~30 min)

5. Wrap-up and workshop evaluation (~10 min)