1. Translating research into practice
Wendy McDonald RN MPH&TM

2. Meaning of Evidence ?
Evidence in best practice includes:
 Research evidence
 Clinical knowledge - experience of the individual
practitioner
 Patient and practitioner preference
 Basic principles from theory and logic

3. Process
 Defined question
 Identify pertinent evidence
 Exhaustive search strategy
 Critically appraise & synthesize
 Reported in standard format
 Implement evidence into practice considering
patient preferences & values

4. Where do you find the evidence?

5. Finding the information
 Electronic databases
 Journal Articles (electronic and paper)
 Internet
 Patient information
 Healthcare records
 Practice based data
 Textbooks

6. Examples of Where to Find
Evidence
 Electronic Search Engines
 Web sources for EBP guidelines
 Professional Organizations
 Literature
Determine what the search will be from what the question
focuses on.

8. Different types of Research Methods…
Randomised Controlled Systematic Meta-Analysis
Trial Review
Cohort Study
Quantitative
Case Control Study
Descriptive Studies
Qualitative

9. Quantitative Research
 In quantitative studies, researchers use objective,
quantifiable data (such as blood pressure or pulse
rate) or use a survey instrument to measure
knowledge, attitude.
 Quantitative research involves analysis of numerical
data.

10. Types of Quantitative Research
 Randomized Controlled Trials
 Cohort study
 Descriptive study
 Case control study

11. Randomized Controlled Trials RCT’s
 The randomized controlled trial is one of the simplest yet
powerful tools of research.
 RCTs are quantitative, comparative, controlled
experiments in which investigators study two or more
interventions in a series of individuals who receive them
in random order.

12. Randomized Controlled Trials cont.
 RCT - A study in which people are allocated at random (by
chance alone) to receive one of several clinical
interventions.
 One of these interventions is the standard of comparison
or control.
 The control may be a standard practice, a placebo, or no
intervention at all.
 RCT seek to measure and compare the outcomes after
the participants receive the interventions.

13. Cohort Study
 A cohort study is a research program investigating a particular group with a
certain trait, and observes over a period of time.
 Observed for the occurrence of certain health effects over some period of
time, commonly years rather than weeks or months.
 The occurrence rates of the disease of interest are measured and related
to estimated exposure levels.
 Cohort studies can either be performed prospectively or retrospectively
from historical records.

14. Case-control Study
 Investigates why certain people develop a
specific illness, have an adverse reaction to a
particular treatment or behave in a particular
way.

15. Case-Control Study
 Research that retrospectively compares individuals who
have a specific condition or disease ("cases") with a group
of individuals without the condition or disease
("controls").
 An application of medical history-taking that aims to
identify the cause of disease among a group of people, or
the cause-effect relationships of a condition of interest.

16. Design of a Case-Control Study
Not Not Exposed
Exposed Exposed Exposed
Disease No Disease
“CASES” “CONTROLS”

17. Case control study
 Often conducted to identify variables that might
predict a condition or disease.
 Case-control studies have proved particularly useful
in studying very rare conditions.

18. Descriptive Study
Examine differences in disease rates among
populations in relation to :
 age
 gender
 race
 and differences in temporal or environmental
conditions.

19. Descriptive Study Continued
 These studies are often very useful for generating hypotheses
for further research.
 Useful in health service evaluation
 Can yield valuable information about a population's health
status, and they can be used to measure risks.
 Used periodically to determine whether a particular service is
improving, if serial description studies all show evidence of
reduced sickness or disability rates over a period of years.

20. Descriptive Study Continued
 can only identify patterns or trends in disease occurrence over
time or in different geographical locations.
 cannot ascertain the causal agent or degree of exposure.
 Examples include the U.S. National Health Care Survey, and
periodic reports from cancer registries.
 Descriptive studies include case reports or case series,
surveillance systems, correlational ( ecological studies) cross-
sectional studies and cluster investigations.

21. Levels of Evidence

22. Systematic Reviews
Uses a detailed search
strategy to find
relevant evidence to
answer a clinical
question.

23. Need for Systematic Reviews
 Complexity of the studies
 Volume of research literature on a given topic
 Bias existing in single studies
 Contradictory results from similar studies
 Sample size variation

24. Has the systematic reviewer done a good
job?

25. Systematic Review
 A summary of evidence, conducted by an expert or
expert panel on a specific topic.
 Uses rigorous process for
 Identifying
 Appraising
 Synthesizing studies
To answer a specific clinical question & draw conclusions &
implications of all research available on a clinical question
based on the data collected.

26. Value of Systematic Reviews
 Brings together and assesses all available research
evidence into a single report about efficacy and
effectiveness of specific practices
 Efficiently integrates valid information
 Provides a basis for rational decision making
 Resolves inconsistencies
 Establishes generalizability
 Assembles evidence
 Increases power and validity of the cause-and-effect
relationship between intervention and outcome
 Limits bias and reduces chance effects

27. What do all of the numbers mean?

28. Meta-analysis
 combines the results of several studies that address a set
of related research hypotheses.
 the statistical synthesis of the data from a set of
comparable studies of a problem.
 yields a quantitative summary of the pooled results.

29. Meta-analysis continued
 aggregates the data and results of many studies, that
used the same or similar methods and procedures.
 reanalyzing the data from all these combined studies.
 generates larger numbers, more stable rates &
proportions for statistical analysis & significance
testing than can be achieved by any single study.

30. Qualitative Research
 Qualitative researchers use methods such as interviews or
narrative analyses to help understand a particular
phenomenon
 Qualitative research involves analysis of data in non
numeric forms such as words (e.g., from personal
interviews), pictures (e.g., video), or objects (e.g., an
artifact).

31. Both
 Triangulated approaches use both quantitative and
qualitative methods
 Regardless of the method they use, researchers must
adhere to certain approaches to ensure both the quality
and the accuracy of the data and related analyses.
 The intent of each approach is to answer questions and
develop knowledge using the scientific method.

33. TRIP
 Turning Research Into Practice (TRIP) Data Base Plus.
 A Data base doing research searches.

34. Implementing Research Findings in
Practice (EBP Cycle)
Need for
a
decision
Implement
findings Information need
Appraise for Formulate
validity and answerable
usefulness Find evidence question
from research

35. Examples of Nursing Research
 Randomized clinical trial examining best practice for
orthopedic-pin site care
 Reliability of methods used to determine NG tube
placement
 The effects of relaxation and guided imagery on
preoperative anxiety
 Quality of life in patients with chronic pain
 The relationship of a preoperative teaching program
for joint replacement surgery and patient outcomes

36. Importance of EBP
 Evidence-based practice helps nurses provide high-
quality patient care based on research and
knowledge.
 Rather than because “this is the way we have always
done it,” or based on myths, hunches, traditions, or
outdated textbooks.

37. Managing variance through EBP
For safe reliable healthcare

38. Study Design
 Good Design = Control
 Researchers need to control several variables
that might affect the outcome of the study:
 Environment
 Subject selection
 Treatment
 Measurement

39. EBP - critically appraise the
evidence for validity
 Validity
 Reliability
 Applicability - transferability
Then synthesize that evidence.

40. Establishing Validity
 Are the result of the study valid?
 What were the results?
 Will the results help me in caring for my patients?

41. Validity
 Validity- were the results of the study
obtained via sound scientific research
methods ?
 Bias or other confounding variables may
compromise the validity of the findings.

42. Bias
 Anything that distorts study findings in a
systematic way – often arises from study
methodology.
 Any tendency to influence the results of a
trial (or their interpretation) other than
the experimental intervention.

43. Bias
 Bias is any deviation of results or inferences from the
truth because of the way(s) in which the study is
conducted.
Blinding: A technique used in research to eliminate bias
by hiding the intervention from the patient, clinician,
and/or other researchers who are interpreting
results.

44. Study Design
Special types of control:
 Blind: Unaware of assigned treatment.
 Double blind: Provider also unaware of assigned treatment.
 Placebo: A look-alike treatment with no efficacy.

45. Confounding
 Confounding variable: A variable which is not
the one you are interested in but which may
affect the results of trial.

46. Reliability – do the numbers add up?
 Do the results of the study have have sufficient
influence on practice clinically and
statistically?
 Can the results be counted on to make a
difference when practitioners apply them to
their practice?
 How large the reported intervention effect was
& how precisely that effect was estimated.
 Together these determine reliability.

47. Reliability – do the numbers add up?
 Do the results of the study have have sufficient
influence on practice clinically and
statistically?
 Can the results be counted on to make a
difference when practitioners apply them to
their practice?
 How large the reported intervention effect was
& how precisely that effect was estimated.
 Together these determine reliability.

48. Another case of
“economy” class
syndrome.
Shouldn’t everyone
take an aspirin and
wear stockings?
What do you think about “flight socks?”

49. Applicability
 Whether or not the results of the study
are appropriate for a particular a patient
situation

50. Applying it to the Patient
 What do the results
mean on average?
 What do they mean for
this patient?

51. Consider Patient Values, Circumstances
 Unique preferences
 Concerns
 Expectations
 Financial resources
 Social supports

52. Are the studies consistent?
 Are variations in results between studies consistent
with chance?
(Test of homogeneity: has low power)
 If NO, then WHY?
 Variation in study methods (biases)
 Variation in intervention
 Variation in outcome measure (e.g. timing)
 Variation in population

53. Critical Appraisal Terminology
 Null Hypothesis
 P-value
 Confidence intervals
 Relative vs Absolute Risk Reduction

54. Null Hypothesis
 States that there is no  Tylenol is better than
relationship between the Advil for headaches
variables being studied.
 Exercising 30 minutes a
 Opposite of what you are day is good for your
trying to find out. health
 Lefthanders are prone to
accidents

55. P-value
 Probability that the  Small p-value dismiss
outcomes are due to chance
chance
 Large p-value means
 Accepted reference that anything is possible
point is .05 (chance, actual effect, or
confounding factors)
 Less than .05 is
statistically significant

56. Statistical Significance
 How strong are the statistical findings?
 What is the strength of the associations/
differences between 2 or more groups?
 What is the proportion of the variance that is
accounted for?
 Statistical significance p-value 0.05 is accepted in
nursing.

57. Confidence interval
 Confidence interval (CI): The range around a
study's result within which we would expect
the true value to lie. CIs account for the
sampling error between the study population
and the wider population the study is
supposed to represent.

58. Confidence Intervals
 Quantifies the uncertainty in measurement.
 A 95% confidence interval (CI) means that one can be
95% confident that the population value falls within a
certain range
 Example: A study states that 40% of a sample of 1000
people are smokers with a CI of 95% +/- 3% means
the frequency of smoking is between 37% and 43%.

59. Risk
 Relative Risk or risk ratio (RR) is the risk for achieving
an outcome in the treatment group relative to that in
the control group
 Relative Risk Reduction (RRR) is the increase in
outcome with the treatment compared to the control
(often expressed as a percentage)
 Absolute Risk Reduction (ARR) is the difference in
outcome rates for two groups, usually treatment and
control

60. Relative Risk or Risk ratio
 Indicates the likelihood (i.e. Risk) that the
outcome would occur in one group compared
to the other.

61. Relative Risk Reduction
 Not a good way to compare outcomes
 Amplifies small differences and makes insignificant
findings appear significant
 Does not reflect the baseline risk of the outcome
event
 Can make weak results look good
 Making weak results look good makes them popular,
thus they are reported in many journal articles
 RRR can mislead

62. Absolute Risk Reduction
 A better statistic to evaluate outcome
 Does not amplify small differences, but shows
the true difference between the experimental
and control interventions

63. Is the review any good?
FAST appraisal
 Question – What is the PICO?
 Finding
 Did they find most studies?
 Appraisal
 Did they select good ones?
 Synthesis
 What do they all mean?
 Transferability of results
Applicability – will the results help me care for my patients?

64. Critical Appraisal of Quantitative Studies
 Why was the study done?
 What is the sample size?
 Are the measurements of major variables valid and
reliable?
 How were the data analyzed?
 Where there any untoward events during the conduct of
the study?
 How do the results fit with previous research in the
area?
 What does this mean for clinical practice?
Melnyk /Fineout-overholt 2011

65. Critical Appraisal of Qualitative Evidence
 Are the results valid/trustworthy and credible?
 Are the implications of the research stated?
 What is the effect on the reader?
 What were the result s of the study?
 How does the research identify the study approach?
 Is the significance/importance of the study explicit?
 Is the sampling study clear and guided by the study needs?
 Are data collection procedures clear?
 Are data analysis procedures described?
Melnyk/ Fineout-overholt 2011

66. Assessing the Studies
 Our job as critical readers is to determine whether
the weakness is serious enough to warrant
reinterpretation of the study's finding.
 We need to question whether the study measures
what it intended to measure and whether the
researchers have accounted for bias and confounding
variables.

67. References
 Greiner, A., & Knebel, E., (Eds.). (2003). Health
professions education: A bridge to quality.
Washington, DC: The National Academies Press.
 Bio medical library University of Minnesota, Evidence
Practice (power point)
http://hsl.lib.umn.edu/learn/ebp/modo1/pico.html
 Malloch, K., Poter-OGrady, T., (2006)Introduction to
Evidence -Based Practice in Nursing and Healthcare .
Sudbury, MA, .Jones and Bartlet

68.  Ireland M. C.(2010) Evidence -Based Practice What does it
mean? Innovations and Perspectives Virginia Department
of Education. 1,2
 Glasziou P. Introduction to EBM 2010(power point)
www.cebm.net/index.aspx?0=1382
 Moseley, M., Evidence - Based Practice - an opportunity
for nursing (2006) (power point) Rocky Mountain
University Provo, Utah. ww.rmuohp.edu/index.

69.  Melnyk, Fine-Overholt Evidence based practice
(2011). Evidence-based Practice in Nursing &
Healthcare. 2nd edition. Philadelphia PA : Lippincot
Williams & Wilkins
 Oakes, J. Evidence Based Practice for Beginners
(power point) www.evidencebasedpractice.org.uk
 Dontje K. J.(2007)Evidence-Based Practice:
Understanding the Process .Topics in Advanced
practice Nursing Journal ,7,4.

70.  Academy of Medical Surgical Nurse, Evidence-based
practice module 1,2 (power point)
www.amsn.org/cgi-bin/WebObjects/AMSNMain
 Glover ,J. Izzo, D.,Odato, K.,Wang, L. (2006) EBM
Pyramid . Yale University School of Medicine.
http://www.ebmpyramid.org/samples/complicated.h
tml