Week 8 Flashcards
what are the 5 steps of the EIP process? (6)
- ground zero
- step 1: ask
- step 2: acquire
- step 3: appraise
- step 4: apply
- step 5: assess
describe the “ground zero” step of the EIP process (2)
- spirit of inquiry
- being curious and reflective
describe the “ask” step of the EIP process (2)
- ASK the burning question
- should be a researchable question and precise
describe the “acquire” step of the EIP process
- SEARCH the literature and evaluate relevancy of research results
describe the “appraise” step of the EIP process
- CRITICALLY APPRAISE the relevant question
describe the “apply” step of the EIP process
- IMPLEMENT decision and INTEGRATE evidence in practice
describe the “assess” step of the EIP process (2)
- EVALUATE the process
- is the change you made actually helping pts?
EIP = ???
- curiousity
- working in cultures of curiousity where we “feel safe” to probe and question is essential for innovation and EIP
what is a question? (4)
- an asking, inquiry, doubt, uncertainty, a difficult matter
- to express doubt about
- to challenge
- dispute
what is the IOWA model (2)
- model used to serve as a guide for nurses to use research findings to help improve nursing care
- triggers nurses to question their practice and seek answers to practices
what are 2 types of triggers used in the IOWA model
- knowledge focused
- problem focused
describe knowledge focused triggers
- generate ideas that stem for new or freshly recognized & disseminated info
what are examples of knowledge focused triggers (4)
- new research hits the media
- new study is published
- nurse attends a conference
- a new commission comes out
describe problem focused triggers
identified by staff through:
- recurrent clinical problems
- risk management
- quality improvement
- quality management problems
- benchmarking data
- financial data
- an issue w care
- often arising from existing data
when do we, as nurses, question their practice? (4)
- identified need for improvement in care delivery & pt outcomes
- difficulties or concerns expressed by nurses or pts
- discrepancy between current nursing practice & what is desirable
- knowledge gaps
what are some common terms nurses can use to expand knowledge gaps (7)
- diagnosis
- prognosis
- intervention or therapy
- etiology
- prevention
- meaning
- education
define: diagnosis
- selection & interpretation of diagnostic tests
define: prognosis
- pts likely clinical outcome
define: intervention or therapy
- selection of a likely beneficial treatment
define: etiology
- factor, process, or condition associated w an outcome
- what caused it
define: prevention
- screening & prevention methods to reduce risk of disease
define: meaning
- pt experience related to an outcome
define: education
- best teaching strategies for colleagues, pts, or family members
define: insanity in practice
- keep doing the same repeatedly and expecting different outcomes in an environment that is steeped in tradition and cultures that promote “this is the way it is done here”
- fear of challenging the status quo causing nurses to stick w old skills & traditions
what is required to overcome insanity in practice? (5)
requires resources to help overcome known barriers such as:
- sheer volume of info
- inconsistent evidence
- lack of time
- lack of resources to search & appraise
- pt demands for certain treatment (may not be evidence informed)
what is pre-appraised literature / pre-processed evidence
- evidence that has been selected from primary studies & evaluated for use by clinicians
what are examples of pre-appraised literature (3)
- summarized research which is presented in an easy to digest way
- synopsis papers (1-2 page papers, which have been condensed from a larger paper)
- summary papers which may include a critique of research (feasibility, pt population, plan to follow up on research, outdated?)
what is a systematic review
- paper that summarizes all existing research evidence on a topic
- scientific approach to summarize, appraise, and communicate the results & implications of several studies that may have contradictory results
what are the key points of a systematic review (3)
- summary of evidence on a given topic
- a methodlogical, scholarly inquiry
- considered a study in and of itself
what is a pro and con of systematic reviews
- may have incredible magnitude
- limited by including the data from only English studies —> germany and china have a great deal of resources for health services and research
what are practice guidelines
- systematically developed statements to assist clinicians and pts in making decisions aboiut care
- ideally, the guidelines consist of a systematic review of the literature, in conjunction w consensus of a group expert decision makers, including administrators, policy makers, clinicians, and consumers who consider the evidence and make recommendations
- take the results of a systematic review and translates them into implemental clinical guidelines (outline recommendations)
describe the pathway to improving health outcomes
clinical problem (need evidence & guidance to make informed healthcare choices) —-> development of systematic reviews —-> developement of clinical practice guidelines —–> improved health outcomes & quality of care
watch youtube video in ppt on other forms of reviews….
…
Dr. Archie Cochrane said we….
- “need properly designed methods to evaluate treatments and only use those effective”
= founder of Cochrane Systematic Reviews (SR)
what is the gold standard in evidence based info
- cochrane SR
what are cochrane SR (2)
- specific method for conducting systematic reviews
- all articles published in this database have the same overall method
what are the key characteristics of SR (6)
- clearly state objectives and a focused clinical question –> PICO (T) or PICo question
- pre-determined inclusion and exclusion criteria
- explicit, reproducible methodology
- explain a systematic search to identify “all studies” that meet eligibility criteria
- a standardized assessment of the validity of included studies (detect the presence of bias)
- a systematic presentation of the synthesis of findings (characteristics and findings in the review)
what is an example of pre-determined inclusion & exclusion criteria
ex.
- should include the years papers were published (ex. all papers up to 2016)
- should include the languages which are included (ex. only English)
what are 4 types of SR
- meta analysis
- meta synthesis
- integrative review
- narrative review
define: meta-analysis (3)
- a high form of SR
- a type of research which uses a statistical approach to combine the findings of numerous empirical studies into a summary study of available data on the given topic
- involves the statistical integration of primary QN studies & observed patterns not previously detected
- basically folds in a bunch of studies on a topic to increase overall sample size & have more generalizable findings, see new patterns
define: meta-synthesis (3)
- a SR involving the integration of primary QL studies
- bringing together qualitative data to form a new interpretation of the research field, helps to build new theories
- more about interpretation versus reduction (as in MA) of info
- looks at phenomena
define: integrative review (2)(
- a SR w no summary statistics due to limitations in studies found (too different to pool)
- more about comparing and contrasting results (QN & QL)
- an approach that allows for the inclusion of diverse methodologies (i.e. experimental and non-experimental research).”
- summarizes past empirical or theoretical literature to provide a more comprehensive understanding of a particular phenomenon or healthcare problem
define: narrative review (4)
- published papers support author’s viewpoint
- general background on an issue
- no explicit and systematic search or evaluate approach
- the author picks papers which support their point, and excludes other valid research
- think: this is like what we do when we write papers for uni*
how is a meta-analysis often depicted
- forest plot (blobbogram)
how is a meta-analysis often depicted
- forest plot (blobbogram) –> reslts of each study plotted on here
a forest plot is constructed using?
- 2 perpendicular lines
what does the horizontal line of a forest plot represent? vertical?
- horizontal = outcome measure (DV)
- vertical = line of no difference = where the intervention had no effect
what do the plots to the right of the vertical line mean? to the left? on the line?
- right = positive effect (increase)
- left = negative effect (decrease)
- on = no difference
the distance of the results from the line of no difference in a forest plot mean?
- represents how large the effect is
- further away = larger effect
- closer = less effect
what do the height of the plotted results mean?
- they do not matter
what occurs after the results are plotted on a forest graph?
- the results are combined & depicted as diamond at the bottom of the forest plot
what occurs after the results are plotted on a forest graph?
- the results are combined & depicted as diamond at the bottom of the forest plot
what does the diamond of the forest graph take into account?
= weighted average effect size for all studies
- the results from all the studies & factors in how effective each study was so you can quickly and easily see a graphic overview or the results
the left and right points of the diamond represent?
- the range of possible effects of the intervention (could have as little as the left end, or an effect as large as the right end)
- the true population effect lies somewhere within this range
by looking to see if any part of the diamond touches the line of no difference, what can we determine
- if it is statistically significant
ex. if doesnt touch = statistically significant
what does the location of the diamond on the plot & how far it is from the line of no difference allow us to determine?
- can determine whether those exposed to an intervention were better off than those not exposed and by how much (ex. if on right side = positive effect)
what does each horizontal line on a forest graph represent
- a study included in the meta-analysis
what do the sqaure/point/diamonds on a forest graph mean? what does a larger size mean?
- point estimate (mean effect estimate)
- larger size = larger sample size
what are key points of clinical practice guidelines (CPGs) (4)
- flexibility (acknowledge the need for a procedure to be altered based on pt preference/needs, acknowledge the variability of a pt group)
- based on a rigorous review of SRs and primary studies
- specific to diagnosis, treatments, procedures, and processes of care
- reduce unnecessary variations in clinical practice
CPGs capture….
- highest quality evidence
CPGs may also be based of…
- resources (ex. we dont take off N95s when they are scarce)
CPGs can be….
- broad or very specific (may explain one procedure or setting general principle for a large scope of practice)
CPGs should be… (3)
- unbiased
- free from traditional views
- have an equity basis (ensure everyone is able to access/apply these guidelines in the same way)
CPGs are not….
- concrete rules –> should not be cookie cutter, guidelines only –> can be tweaked in a community or setting w unique pt populations –> need to be used w clinical judgement
what are the features of CPGs (5)
- recommendations made for practice based on systematic reviews of evidence along w benefits and harms
- the strength and quality of the evidence may vary for each recommendation
- can be many guidelines for one topic
- can be differences in rigor of development and interpretation of evidence resulting in different or conflicting recommendations
- appraisal of CPGs required before uptake
how can we determine which guideline is best? (3)
- review how the guideline was created
- are key experts involved in this guideline?
- when was this published?
what are some CPG sources (4)
- google –> “practice guidelines” + clinical area or intervention
- (Canada) Registered Nurses Associated of Ontario
- (USA) National Guidelines Clearinghourse (sponsor agency for healthcare quality & research, US Dept. of Health and Human Services); a public repository
- see box 8.1 Selected Guideline Data bases
what is the objective of the RNAO guideline for person- and family-centered care
- to promote the evidence-based practices associated w person and family-centered care, and to help nurses and other HCP acquire the knowledge and skills necessary to become more adept at practising person- and family-centered care
levels of evidence reflect to the quality of CPGs. what are the levels of evidence? (10)
1a. systematic reviews (with homogeneity) of RCTs
1b. individual RCTs (with narrow confidence interval)
1c. all or none RCTs
2a. systematic reviews (w homogeneuity) of cohort studies
2b. individual cohort study or low quality RCTs (ex. <80% follow up)
3a. systematic reviews (with homogeneity) of case-control studies
3b. individual case-control study
4. case series (and poor quality cohort & case control studies)
5. expert opinion without explicit critical appraisal, or based on physiology, bench research, “first principles”
for the RNAO person- and family-centered care guideline, the ppt lists a bunch of recommendations, im assuming we dont have to memorize this? maybe just review the ppt
…
describe the future directions of CPGs (5)
- movement toward international collaborations
- condensing CPGs for download on hand-held devices
- transdisciplinary CPGs
- system-lvl clinical decision making tools based on CPGs and availability in electronic medical records
- follow the RNAO – a worldwide leader & collaborator in electronic capture of nurse decision-making – where nursing care provides benefit to the pt, organization, and system
what are the 7 phases of the knowledge to action cycle
- identify knowledge to action gaps
- adapt knowledge to local context
- assess barriers/facilitators to knowledge use
- select, tailor, implement interventions
- monitor knowledge use
- evaluate outcomes
- sustaining knowledge use
