2. Objectives
• Clarify the differences between evidence
based practice and translational research.
• Describe models for introducing research
findings into practice.
• Identify barriers to research utilization in
practice.
3. Introduction
• Evidence-based practice, translational
research and research utilization are all words
which have been used to describe the
application of evidential knowledge to clinical
practice.
• In evidence-based practice, the goal is to
decrease practice variability, increase patient
safety and eliminate unnecessary cost.
4. Research Utilization and
Translational Research
• Research utilization is a subset of evidence-
based practice.
• Translational research is used to describe
the translation of medical, biomedical,
informatics and nursing research into
bedside clinical interventions.
• Research results are crucial to furthering
evidence-based practice.
5. What is Evidence?
• Discussion abounds in the area of what
constitutes evidence.
• Considered the most reliable, the randomized
control trial (RCT) is often termed the gold
standard for evidence.
• Evidence includes standards of practice, codes of
ethics, philosophies of nursing, autobiographical
stories, esthetic criticism, works of art, qualitative
studies and the patient and clinical knowledge.
6. Hierarchy of Evidence
• In order to use evidence in practice, the weight
or validity of the research must be determined.
• An example of an evidential hierarchy by Stetler
et al. (1998) prioritizes evidence into 6
categories:
– Meta-analysis
– Individual experimental studies
– Quasi-experimental studies
– Non-experimental studies
– Program evaluations such as quality improvement projects
– Opinions of experts
7. Weight of Evidence
• The hierarchy identifies meta-analysis as the
best quality evidence since it utilizes multiple
individual research studies to come to
consensus.
• Qualitative research allows us to understand
the way in which the intervention is
experienced to the researcher and to the
participant as well as the value of the
interventions to both parties.
8. Bridging the Gap Between
Research and Practice
• requires an understanding of the key
concepts and barriers,
• accessibility to research findings,
• access to clinical mentors for research
understanding,
• a reinforcing culture and
• a desire on the part of the clinician to
implement best practices.
9. Barriers to Applying Evidence to
Practice
• lack of time
• lack of access to libraries within the facility
• lack of technology confidence
• lack of knowledge on how to search for
information
• lack of value assigned to using research in
practice.
10. Bridging the Gap Between
Research and Practice
• In an observational study of the information
seeking behaviors of on-duty nurses, McKnight
(2006) noted that nurses did not feel ethically
comfortable with taking time from patient care to
read publications, nor was much time available.
• Nurses may see the job of interpreting research
as too complex or may see the organizational
culture as a barrier to implementation.
11. Technology and Research
• The collaborative component of research is
supportive of informatics science.
• Technology has become so important to
research that the National Institutes of
Health has invested in re-engineering of
the clinical research enterprise as part of its
roadmap initiative for medical research
(National Institutes of Health, 2007).
12. The role of informatics
• An informatics infrastructure is critical to
supporting a clinician’s access to information in a
clinical setting.
• As an example of the integration of informatics
and the medical record, Matter (2006) describes
the positive effects of a successful integration of
referential links with EBP clinical content in the
clinical pathway on patient outcomes.
13. Gathering Evidence for Practice
• The Cochrane Collaboration showed an increasing
need to improve on the speed of knowledge
acquisition and access to evidence.
• With the goal of promoting the use of research
findings, and tool use based on these findings, the
Agency for Health Care Research (AHRQ) became
an active participant in pushing evidence forward
into practice.
14. Agency for Healthcare Research
and Quality
• The AHRQ (AHRQ.gov) is a government
sponsored organization with the mission of
reducing patient risk from harm, decreasing
healthcare cost and improving patient
outcomes through the promotion of
research and technology applications
focused on evidence-based practice.
15. National Guidelines Clearinghouse
• Part of an AHRQ initiative
• NGC is a comprehensive database of
evidentially based clinical practice guidelines
and related documents which are regularly
published through the NGC listserv and are
available on the NGC website
(http://www.guideline.gov/).
16. More on NGC
• The NGC website allows users to browse the
website for the clinical guidelines, view abstracts
and full text links, download full text clinical
guidelines to personal digital assistive (PDA)
devices and smartphones, obtain technical
reports and compare guidelines.
• There are a growing number of written and
electronic resources available to assist in creating
guidelines and offering information about
evidence-based practice.
17. PubMed4Hh
• Pub Med for handhelds
• powerful and free app for smart phones
that provides access to the National Library
of Medicine
– supports PICO searches, clinical queries and
multi-language searches
– provides links to consensus abstracts.
18. Developing Evidence-Based
Practice Guidelines
• Careful analysis and discussion of the
research and/or other forms of evidence in
this scenario may reveal that given the
context, implementation may not be
practical.
• Information technology is important in
synthesizing the research regardless of the
model.
19. Meta-analysis and Generation of
Knowledge
• The strength of the systematic review is its
ability to corroborate findings and reach
consensus.
• Systematic reviews show the need for more
research by revealing the areas where
quantitative results may be lacking or
minimal.
20. Meta-analysis and Generation of
Knowledge
• Meta-analysis, a form of systematic review,
uses statistical methods to combine the
results of several studies.
• Meta-analysis is “the statistical analysis of a
large collection of analysis results from
individual studies for the purpose of
integrating the findings.”
21. Meta-analysis Steps
1. defining the problem followed by protocol
generation
2. establishing study eligibility criteria followed by
literature search
3. identifying the heterogeneity of results of
studies
4. standardizing the data and statistically
combining the results
5. sensitivity testing to determine if the combined
results are the same
22. Meta-analysis Disadvantages
• The often sited criticism of meta-analysis is
that emphasis is on quantitative studies, not
qualitative.
• The analysis is only as good as the studies
used in the analysis.
• Collection and dissemination of these meta-
analysis and systematic reviews are available
in paper and on-line through the internet,
although many such databases require a
subscription.
23. Open Access
• There are two vehicles for Open Access:
– archives
– journals
• Open Access journals are generally peer-reviewed
and freely available.
• The publishers of open access do not charge the
reader but obtain funds for publishing elsewhere.
• Open access journals may charge the author for
publishing.
24. Thought Provoking Questions
1. Twelve hour shifts are problematic for patient and nurse
safety and yet hospitals continue to keep the 12-hour
shift schedule. In 2004, the Institute of Medicine (Board
on Health Care Services & Institute of Medicine, 2004)
published a report which referred to studies as early as
1988 which discussed the negative affects of rotating
shifts on intervention accuracy. Workers with 12 hour
shifts realized more fatigue than workers on 8 hour
shifts. In another study done in Turkey by Ilhan et
al(Ilhan, Durukan, Aras, Turkcuoglu, & Aygun, 2006),
factors relating to increased risk for injury were: age of
24 or less, less than 4 years of nursing experience,
working in the surgical intensive care units and working
for more than eight hours. As a clinician reading these
studies, what would your next step be?
25. Thought Provoking Questions
2. The use of heparin versus saline to maintain the patency
of peripheral intravenous catheters has been addressed in
research for many years. The American Society of Health
System recently Pharmacists (ASHSP) published a position
paper in January 2006 (American Journal of Health System
Pharmacists, 2006) advocating their support of the use of
0.9% saline in the maintenance of peripheral catheters in
non-pregnant adults. It seems surprising that their
position paper references articles that advocate the use of
saline over heparin dating from 1991. What do you feel
are some of the barriers which would have caused this
delay in implementation?
