Evidence-based Nursing Practice, Part 2

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of time, lack of support, limited nursing interest, lack ... Iowa Model for Research Based Practice to Promote. Quality of Care in which various triggers assist in.

JONA Volume 32, Number 2, pp 85-90 ©2002, Lippincott Williams & Wilkins, Inc. http://www.nursingcenter.com

Evidence-based Nursing Practice, Part 2: Building Skills Through Research Roundtables Rose Maljanian, MBA, RN Laura Caramanica, PhD, RN S. Kelly Taylor, AS Joan B. MacRae, MS, RNC Dawn K. Beland, MSN, CCRN, CS Numerous articles describe barriers to nurses conducting research and achieving evidence-based practice as well as strategies for overcoming barriers.The Research Roundtable format is one such strategy. It is an interactive means for providing novice nurse researchers and nursing students with the skill sets required to drive application of existing evidence to nursing practice and conduct outcome studies to derive new evidence. The authors discuss their Research Roundtable series that addressed a number of barriers to research, research utilization, and evidence-based practice and how the series increased nurses knowledge and skills, demystified the research process, provided role models, demonstrated managerial and collegial support, and provided library, fiscal, and other resource support to complete staff projects.The details of the Research Roundtable series will guide others in replicating the process in their own organizations and academic communities. Barriers to nurses conducting research include lack of time, lack of support, limited nursing interest, lack of knowledge, perception that research is an intimidating process, lack of support by nurse managers, lack of money and library resources, resistance to change, and the mindset of using established practices.1 Recent studies conducted in Canada,3 Sweden,4 the Republic of China,5 Australia,6 and Northern Ireland7 are consistent with many of these barriers and additionally include insufficient author-

Author affiliation: Hartford Hospital, Hartford, Conn. Corresponding author: Rose Maljanian, MBA, RN, Institute for Outcomes Research & Evaluation, Hartford Hospital, 80 Seymour Street, P.O. Box 5037, Hartford, CT 06115 ([email protected]).

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ity to change practice3,4,6,7 readability of studies6,7 and lack of colleague support.4-6 Less literature addresses innovative strategies to overcome such barriers. Reports focus on targeted education based on needs assessment,8 and basic initiatives such as subscribing to professional journals, reviewing integrative research reports, participating in journal clubs and attending and presenting at professional conferences.9,10 General strategies and support include creating a culture of scientific inquiry10 and making research relevant to nurses, providing education, affording the necessary resources, requiring evidence-based practice and research as an expectation, and aligning efforts with goal setting, offering rewards, and framing research and evidence-based practice as what caring nurses do as part of routine practice.11 Cronewett, in particular, emphasizes the dissemination of research as the first step to getting research into practice and the need to disseminate the findings in an efficient, interpretable format for the practicing clinician.9 Dooks12 addresses similar strategies based on the theoretical framework described by Rogers in his Diffusion of Innovations model,12 a theoretical framework also referenced by Cronewett. The focus of the Rogers model is the cultural and behavioral issues that influence change. Strategies addressed by Dooks based on this model include identifying early adopters and skilled role models such as clinical nurse specialists and advanced practice registered nurses, as well as providing education, providing ongoing supports, and incorporation of research and evidence-based practice as a value in job interviews and performance appraisals.Titler and colleagues10 describe the Iowa Model for Research Based Practice to Promote Quality of Care in which various triggers assist in identifying issues and the evidence-base is evaluated 9

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for application to clinical practice. Titler also describes an extensive infrastructure to promote uniformity of the process across the organization. One practical strategy reported in the literature describes the development and implementation of an Evidence-based Practice Committee and Web Guide to Evidence-based Practice at a general hospital in Canada. In another report, Warren and Heermann include in their staff nurse focused model to disseminate and use research findings, a unit-based approach in which each clinical unit has a designated research area, Research Corner, to post articles, display study findings through posters, and hold rounds to discuss research findings. As part of this model, nurse research interns are identified by nurse managers to participate in training and develop the unit’s initiatives. Despite the above advances in identifying of barriers and strategies to overcome them, there remains a need to develop additional new strategies to overcome barriers to research, research utilization, and evidence-based practice. 2

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The Research Roundtable The Research Roundtable format is a pragmatic strategy implemented locally by the Capital Area Alliance for Nursing Research (CAANR),16 a collaboration of neighboring university faculty and healthcare institutions, for overcoming a number of the barriers reported in the literature. Purpose The Research Roundtable series are an interactive means for providing novice nurse researchers and nursing students with the skill sets required to apply evidence base into nursing practice and to conduct outcome studies to derive new evidence. The Research Roundtable series presented by CAANR consists of 4 sessions held each fall and spring semester.

The 4 sessions are 1) conducting a literature search, 2) literature critique A, 3) literature critique B, and 4) applying evidence base to practice and conducting an outcomes research study (Table 1). From an educational perspective, the Roundtable format is informal and by its nature allows for guided discussion rather than a typical didactic session that allows 10 minutes for questions for every structured 50 minutes of lecture. Process Each Research Roundtable series is hosted by a clinical team dedicated to defining a study topic, completing a comprehensive literature review and applying findings to practice and/or conducting an outcomes research study. Women’s Ambulatory Health Services, for example, selected health risk assessment as their topic and designed a study to evaluate the effectiveness of an intervention in reducing health risk in their patient population. The team commits not only to attending the formal Roundtable sessions but also to interim meetings to prepare for the sessions and once the sessions are complete to follow through with implementation of the study.The benefit to the team for the additional energy they expend is the support they receive from faculty and outcomes research staff in achieving their study and population health improvement goals. In addition, work completed by a number of the teams had led to opportunities for presentation at professional meetings and for subsequent grant funding. Education Management Participants receive contact hours for all sessions.Although Connecticut is not a mandatory continuing education state for relicensure, staff find the contact hours beneficial in meeting continuing education requirements if they maintain licensure in mandatory

Table 1. Research Rountable Series-Sessions Session

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Topic

One Two

Searching the Literature Critiquing the Literature A

Three

Critiquing the Literature B

Four

Evidence-based Practice and Outcomes Research

Faculty Senior Librarian University Faculty Director, Outcomes Research University Faculty Director, Outcomes Research Director, Outcomes Research

Format (All 1 Hour) Formal presentation: search process case study Facilitated discussion using critique tool Facilitated discussion using critique tool Formal presentation: methods and application case study

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continuing education states, and/or to meet certification requirements of credentialing organizations. As an approved provider unit, each educational session is awarded 1.0 contact hour. Documentation must meet American Nurses Credentialing Center criteria. 15 Once the Research Roundtable series topic is selected and faculty identified, curriculum plans are developed, including learner objectives and supporting content outlines for all sessions. Promotion Promotion of the Research Roundtable series is accomplished using a variety of mechanisms. A brochure is designed for each series that identifies the chosen topic of study, dates, times, and locations, as well as the focus and skill building element to be addressed at each session. Brochures are distributed to all alliance member organizations and the information is posted on the hospital’s Intranet and hospital’s and CAANR’s Internet Web sites. Participants are encouraged to preregister for each session in order to facilitate timely distribution of the assignments.This provides adequate time for staff to read and critique the chosen article prior to discussion at each scheduled session. Evaluation At the conclusion of each session, participants are asked to evaluate the session in writing using a standard evaluation form. Participant comments are shared with the facilitators and faculty on an ongoing basis. Evaluative feedback provides the coordinating team with helpful data regarding adequacy of time scheduled, appropriateness of level of content presented, level of achievement of identified session objectives and the staffs’ perception of applicability of content to their practice settings.

Content of the Sessions Literature Search (Session 1) The first session of the Roundtable focuses on reviewing the literature. Skill building includes formulating an effective search strategy. Key to this session is a meeting, prior to the first Roundtable, of the research project team with the medical librarian. Team members discuss their proposed research and determine key questions to be answered through a review of the literature. The medical librarian guides team members in developing an effective search strategy. A search is then

conducted, with team members present, and articles are selected to support the research project. From this usually larger group of articles, 2 articles are identified for use at the Roundtable critiquing sessions. At the first Roundtable session, the medical librarian describes the process for Roundtable participants.This introduces the group to the need for using knowledge-based information to support research and evidence-based practice.The medical librarian also provides information about various databases and online resources available for retrieving literature. Steps in formulating a search strategy (Figure 1) are reviewed and an online demonstration of the process is conducted. Questions and discussion are encouraged throughout the demonstration so that participants have the opportunity to learn effective searching skills using examples relevant to their nursing practice. Critique of the Literature (Sessions 2 and 3) Prior to each of the two critiquing sessions, a single article is selected and distributed to program registrants. In addition to the featured article, a critique tool modified from Castle16 is distributed with the expectation that each registrant review the article and attempt to answer each of the questions outlined in the critique tool prior to the session. Examples of critique tool questions are: Are the title and abstract helpful to the reader to determine if the full article is useful to read? What is the problem statement, broad objective of the study, and the hypotheses or research questions? What is the research design? Are the instruments used reliable and valid? Are the statistical analyses used appropriate for the study? And finally, what are the major findings of the study and are they useful to practice? The critique of the articles includes a determination of whether or not the article represents substantial evidence on which to base a practice change. For learning purposes, one of the selections typically includes an article that has some substantial limitation to emphasize to participants the need for a careful critique before assuming that all published works contain valid evidence simply based on the fact that they were published. Examples include articles that fail to clearly identify the research question or study purpose; lack of rigor in study design; use of instruments without established reliability, and validity and failure to report any prospective testing of the instrument; and inconclusive results related to small sample sizes reported as a true negative finding.

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Figure 1. Formulating a search strategy.

Evidence-based Practice/Outcomes Research (Session 4) Session 4 Preparation

Based on the literature review and critique of selected articles, the clinical team with guidance from Roundtable faculty determine if the literature: 1) supported that no change in practice be made, 2) provided some useful but limited recommendations (eg, a structured approach for measuring a behavior change), 3) provided evidence to support a practice change, or 4) confirmed a gap in knowledge requiring further study.When indicated as a result of going through the above decision-making process, a process similar to that described by Titler and colleagues, in The Iowa Model10, more often than not, the teams participating to date have elected to move forward with a prospective study to further expand the available evidence in their practice area as well as increase their skills in the research process. In between formal sessions 2 and 4 held with the entire group, a number of meetings take place with the study team and the Director of the Institute

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for Outcomes Research and Evaluation. In the first meeting, the research aims and hypotheses are refined based on the findings from the literature search and input from other members of the multidisciplinary team. As example, when designing a study to evaluate short-term outcomes in the congestive heart failure patient, it was determined that the readmission rate was an unrealistic primary endpoint due to the large sample size requirement. Since the intervention involved patient education, it made more sense and was more scientifically valid to evaluate outcomes in terms of patient knowledge and symptoms post discharge. Readmission rates, still of concern, were defined as a secondary aim to be evaluated, avoiding potentially false conclusions due to lack of sufficient statistical power. The next several meetings focus on research design and study methods.This includes further definition of the study population (ie, identification of inclusion and exclusion criteria), determining which research design is most scientifically valid and feasible to conduct based on logistics of patient and

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staffing flow, available resources, and sample size available as it relates to the sample size required to test the research hypotheses as stated. One study team for example focused on nurse caring behaviors and an intervention to enhance staff understanding and internalization of caring behaviors. Due to feasibility issues with staff assignments it was not possible to construct the study using a randomized design.A pre/post design was employed instead with measures taken to reduce the potential of bias and unequal patient cohorts. The final meeting held prior to the 4th Roundtable session involves preparation for presentation to the entire group of registrants in the Roundtable series.The Director for Outcomes Research serves as faculty for the session. This session while including a formal presentation is left informal enough so that participants can ask questions and members of the study team can interject their personal experiences with the process. Session 4 Content

The session begins with an introduction to evidence-based practice.The research process is then reviewed using the study developed by the team as a case example. For instance, the difference between broad study aims and specific research hypotheses are described followed by a slide that lists the actual aims and hypotheses defined by the study team. The pros and cons of various research designs are explained as well as factors that introduce bias into studies. Given the limit of the 1 hour session, a brief overview of statistics is provided to include sample size estimation with the purpose of preparing nurses for asking educated questions when meeting with a statistician rather than the more extensive preparation required if they were to conduct the analyses themselves.The presentation concludes with a description of the study implementation plan and next steps for the study team. At this point, it is emphasized to the group that the presentation involves only a basic outline for the study and that future meeting between the Director for Outcomes Research and the study team will need to take place in order to refine study procedures and prepare for implementation.

Roundtable Series Follow-up The Director for Outcomes Research continues to support the study team in securing necessary fund-

ing or resources required to implement and complete the study.This includes iterative feedback on post-implementation enrollment statistics, data capture and quality, and finally study results, interpretation and application to practice. Given that the Roundtable series has been in place for 3 years, the Director is simultaneously working with new groups just getting started in identifying their topic through the formal Roundtable series, those in phase 2 who have implemented their studies, and those in phase 3 who have completed their studies and are in the process of analyzing and interpreting the study results and applying the new knowledge into practice.

Conclusion The Research Roundtable series simultaneously addresses a number of barriers to research , research utilization and evidence-based practice reported in the literature.The Research Roundtable series have reached hundreds of practicing nurses, affiliating nursing students, and 6 clinical teams caring for high risk, high volume patient populations including diabetes, pneumonia, adolescent psychiatric, general surgical, congestive heart failure and women’s health ambulatory service patients. In addition, opportunity is provided for staff presentation of study findings via poster or oral presentation at our annual nursing research conference and other venues. With replication of this process at other sites and advancement of other strategies to reach the nursing community, nursing scholars and leaders can have a tremendous impact on advancing evidence-based, high-quality care within the next decade. Acknowledgment The authors thank the members of the Capital Area Alliance for Nursing Research (Hartford Hospital, John Dempsey Hospital, Middlesex Hospital, MidState Medical Center, Connecticut Children’s Hospital, University of Connecticut, University of Hartford, Central Connecticut University, St. Joseph’s College, and Capital Community College), and the faculty members who have participated in the Roundtable series as well as the nursing directors and clinical teams who have dedicated their time to sharing their experience with other Roundtable participants and improving care in their clinical services.

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9. Cronenwett LR. Effective methods for disseminating research findings to nurses in practice. Nurs Clin North Am. 1995;30(3):429-438. 10. Titler MG, Kleiber C, Steelman V, et al. Infusing research into practice to promote quality care. Nurs Res. 1994;43(5):307313. 11. Maljanian R. Supporting nurses in their endeavor for achieving evidence-based practice. Outcomes Manage Nurs Pract. 2000;4(4):155-158. 12. Dooks P. Diffusion of pain management research into nursing practice. Cancer Nurs. 2001;24(2):99-103. 13. Warren JJ, Heermann JA. The research nurse intern program. J Nurs Adm. 1998;28(11):39-45. 14. Caramanica L, Maljanian R, McDonald D, et al. Evidence based nursing practice, part 1: a hospital and university collaborative. J Nurs Adm. 2002;32(1):27-30. 15. Connecticut Nurses’ Association. Manual for Continuing Education Approval for Providers. Meriden, CT: Connecticut Nurses’ Association; 1998:20-34. 16. Castle M. Primer of Nursing Research. Philadelphia: Saunders; 1987.

JONA • Vol. 32, No. 2 • February 2002 • http://www.nursingcenter.com