Processes and outcomes of evidence-based practice

Implementing Clinical Practice Changes: A Practical Approach

Implementing changes in clinical practice is critical for insuring the highest quality patient care. Ideally, changes in clinical practice should be based upon high-quality research findings or so-called evidence-based medicine. The increase in health care expenditures and data on the variance in clinical practices are exerting external pressures on professionals to justify practice patterns and are now tightly linked to reimbursement. As these factors fuel tensions between quality practice and care on one hand and cost on the other, clinicians must increasingly be prepared to justify the processes and resources used to deliver the required care to produce optimal patient outcomes. Continuously monitoring the clinical literature and implementing clinical practice changes, when a sufficient body of evidence exists, will contribute to improved patient outcomes. This involves three practical steps: (a) examining and evaluating the research, (b) gauging the likelihood of success, and (c) recommending and implementing a clinical practice change.

Symptom management in palliative care and end of life care

There is a need for generalist- and specialist-level palliative care clinicians proficient in symptom management and care coordination. Major factors contributing to this need include changed disease processes and trajectories, improved medical techniques and diagnostic testing, successful screening for chronic conditions, and drugs that often prolong life. The rapid progressive illnesses and deaths that plagued the first half of the twentieth century have been replaced in the twenty-first century by increased survival rates. Conditions that require ongoing medical care beyond a year define the current chronic illness population. Long years of survival are often accompanied by a reduced quality of life that requires more medical and nursing care and longer home care. This article reviews the management of selected symptoms in palliative and end of life care.

Importance of nursing leadership in advancing evidence-based nursing practice

Our patients depend on us to do the best on their behalf. If we do not take accountability for our practice, continually examining what is the best way to deliver care, we are limiting our role to technical skills and not fully actualizing our professional role. [Evidence-based practice] is essential to practicing safely as nurses (p. 53).1.

Illuminating the processes of knowledge transfer in nursing

RATIONALE

Over the past 10 years, there has been a propensity to translate research findings and evidence into clinical practice, and concepts such as knowledge transfer, research dissemination, research utilization, and evidence-based practice have been described in the nursing literature.

AIM

This manuscript shows a selective review of the definitions and utilization of these concepts and offers a perspective on their interrelationships by indicating how knowledge transfer processes are the basis of all the concepts under review.

FINDINGS

Definitions and utilization of knowledge transfer in the literature have been influenced by educational and social perspectives and indicate two important processes that are rooted in the mechanisms of research dissemination, research utilization, and evidence-based practice. These processes refer to a cognitive and an interpersonal dimension. Knowledge transfer underlies a process involving cognitive resources as well as an interpersonal process where the knowledge is transferred between individuals or groups of individuals.

CONCLUSION AND IMPLICATIONS

This manuscript can contribute to our understanding of the theoretical foundations linking these concepts and these processes by comparing and contrasting them. It also shows the value and empirical importance of the cognitive and interpersonal processes of knowledge transfer by which research findings and evidence can be successfully translated and implemented into the nursing clinical practice.

Alignment of pain reassessment practices and National Comprehensive Cancer Network guidelines

PURPOSE/OBJECTIVES

To improve nursing pain reassessment practices using a research utilization model and advanced practice nurses (APNs).

DESIGN

A pre- and postintervention one-group design.

SETTING

A cancer hospital located in the western United States.

SAMPLE

42 oncology RNs from the inpatient staff of medical or surgical oncology units working at least 24 hours per week.

METHODS

National Comprehensive Cancer Network clinical practice guidelines were adopted. Interventions included one-on-one feedback regarding reassessment practices and nursing pain rounds. Instruments used were Nurses' Knowledge and Attitudes Survey Regarding Pain (NKASRP), Pain Reassessment Data Tool, and Pain Competency Evaluation (PCE).

MAIN RESEARCH VARIABLES

Independent variables were pain rounds and one-on-one feedback. Dependent variables were PCE scores, percentage of pain reassessment documentation, and NKASRP test scores.

FINDINGS

Changing staff pain practices requires more than education. Barriers may be overcome through careful planning, using a systematic change process such as a research utilization approach. NKASRP and PCE scores and a percentage of reassessment documentation reached statistically significant increases postintervention.

CONCLUSIONS

Adapting research recommendations allowed staff to create unit-specific solutions, evaluate practice changes, establish research partnerships, and use research in bedside care. Staff increased their proficiency in pain reassessment practices after the intervention.

IMPLICATIONS FOR NURSING

Research utilization models bring about desired practice changes under APN leadership. Aligning pain reassessment practices with clinical pain guideline recommendations promotes improved pain management through better reassessment documentation.

"Research to Practice": A Practical Program to Enhance the Use of Evidence-Based Practice at the Unit Level

PURPOSE/OBJECTIVES

To assist clinical nurses in translating research into clinical practice.

DATA SOURCES

City of Hope Quality-of-Life (QOL) Model to guide presentations and discussion, research utilization theories, and evidence-based practice literature.

DATA SYNTHESIS

Based on percentage of individual participant involvement, the four domains of QOL, and a knowledge survey.

OUTCOMES

Attendance, discussion, QOL domain ranking, satisfaction, and pre- and postknowledge scores. Attendance averaged 13 individuals; average discussion participation was 54%. The psychological QOL domain was most important (58%), and discussion averaged a score of 3 (1 = slow to 5 = lively). A one-point increase (scale 1-5) measured a change in knowledge.

CONCLUSIONS

The challenge for nursing assessment is to fully address patient issues in the psychological domain.

IMPLICATIONS FOR NURSING

A practical program can be formulated to bring evidence-based practice to the clinical setting.

A process model for evidence-based literature syntheses

PURPOSE/OBJECTIVES

To describe the development and implementation of the Triad Model of Research Synthesis, developed as a mechanism to produce systematic literature reviews that can serve as sources of evidence for decision making in health care.

DATA SOURCES

Authors' recollections of the development and implementation process over a one-year period during 2002. Tracking forms were completed by members of three triad teams as they compiled research syntheses on clinical topics: pharmacologic treatment of dyspnea, assessment of sleep disturbances in patients with cancer, and exercise as an intervention for cancer-related fatigue.

DATA SYNTHESIS

The systematic literature review process includes the following steps: (a) organize, search the literature, and focus the research synthesis question; (b) critique the selected literature; (c) synthesize the evidence; and (d) write. On average, triad members spent hours that were equivalent to full-time work during the year (excluding completion of manuscripts) on the synthesis projects. Hours spent varied by member role and with each phase of the process.

CONCLUSIONS

Performing a research synthesis using the triad model was a productive and resource-intensive experience that points to the need for negotiating resources prior to embarking on such an exercise.

IMPLICATIONS FOR NURSING

Given a group of highly motivated nurses and others with adequate time and resources, this model can be effective when developing systematic reviews about a variety of topics. Literature syntheses developed can be used as evidence for clinicians and others to develop practice protocols and other evidence-based care guidelines.