Research Utilization M6728 Class4 Thanks to Dr. Elaine Larson for many of these slides.
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Transcript of Research Utilization M6728 Class4 Thanks to Dr. Elaine Larson for many of these slides.
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Research Utilization
M6728
Class4
Thanks to Dr. Elaine Larson for many of these slides
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Idea to Implementation
• Before 1920 30 years
• Until 1965 9 years
• 1980s 2-5 years
• Now Depends
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Research Utilization
Why does it take so long?
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Antisepsis as a Case Study
• Holmes, U.S.• 1840-82• Direct transmission of
infection• Ridiculed by peers
• Semmelweis, Austria• 1845-61• Hands as transmitter
of infections• Lost his job
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Antisepsis
• Nightingale, England• 1854-90• Importance of
sanitation and clean environment
• Despite resistance, had success
• Lister, Scotland• 1856-85• Antiseptic surgery• Acceptable within a
few years
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Stages of Innovation
• Awareness (knowledge)
• Persuasion (belief)
• Occasional Use
• Regular Use
(Brett, 1987)
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Adoption of Practices (n=216)
010
2030
405060
7080
90100
IV TF Urine Pain Goal
AwareImplement
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Why Don’t Nurses Use Research?
Don’t know about the findings: 11% nurses read a journal
weekly, 41% monthly (Retsas, 2000)
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Why Don’t Nurses Use Research?
Don’t understand or cannot assess
the findings
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Varying PerspectivesResearcher Clinician
• Comfort with probability and tentative answers
• Wants to discover common patterns and similarities
• Goal to extend general knowledge
• Seeks/needs clear prescriptions
• Views each patient as unique
• Wants to apply knowledge
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Why Don’t Nurses Use Research?
They don’t believe the findings
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What Does It Take to Change Practice?
• Dissatisfaction with present situation
• Perception that there are or could be acceptable alternatives
• Confidence in ability to change
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Why Don’t Nurses Use Research?
They don’t know how to apply the findings
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Differing SkillsResearcher Nurse Consumer• Generates questions• Develops designs and
methods• Collects and analyzes
data• Interprets data• Communicates
findings
• Generates questions• Uses knowledge for
patient care• Evaluates relevance
and utility of studies• Transfers information
to practice• Evaluates effects
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Why Don’t Nurses Use Research?
There aren’t any findings
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Survey of 400 Nurses
• What would help nurses use research?
• Most prevalent response: RESEARCH THAT IS RELEVANT AND APPLICABLE
(Retsas, 2000)
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Why Don’t Nurses Use Research?
They are not allowed to use the
findings
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It’s changing*….
• Survey of 204 critical care nurses, 1999
• 11/12 practice innovations being used
*Thompson, NINR State-of-Science Congress, 9/99
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Correlates of research use*….
• Positive: individual innovativeness, using communication channels
• Negative: years of nursing experience
*Thompson, State-of-Science Congress
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Barriers to Implementation
• Failure of researchers to communicate
• Divisions between education, research, practice
• Studies lack relevance to practice
• Confusion about conduct and use
• Disparity in education of nurses
• Institutional barriers
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Assessing Relevance to Practice
• Evaluate quality of scientific base
• Assess relevance to the practice setting
• Determine potential for evaluation
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Possible Outcomes
• May meet its goal, solve a problem
• May result in no noticeable change
• May be harmful and need to be stopped
• Results may be totally unexpected
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WICHE
• First major utilization project, mid-1970s
• Funded by Division of Nursing
• Five phases: recruitment, workshop, change agent, second workshop after 5 months, followup
• Difficulty finding clinical studies
• Three published reports
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CURN
• 1975-80, Mich State Nurses’ Assoc
• 34 hospitals participated
• Structured, formal organizational process
• Required organizational commitment, resources, research expertise
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Assumptions of CURN Model
• Organization must be committed
• Visible, potent, enduring mechanisms vital
• Substantial resources necessary
• Planned change is essential
• Two or more studies are required to support change
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Ten CURN Clinical Protocols
• Preop teaching, decubitus prevention
• Reducing diarhhea in tube-fed patients
• Clean intermittent urinary cath
• Mutual goal setting, reducing pain
• Stress reduction, IV cannula change
• Preop sensory preparation
• Lactose free diet
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Criteria for Using Research:CURN
• Evaluating and integrating studies for the research base– Replication (at least two studies)– Scientific merit– Risk
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Criteria for Using Research:CURN
• Relevance– Clinical merit– Clinical control– Feasibility– Cost benefits
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Criteria for Using Research:CURN
• Potential for Clinical Evaluation
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Stetler/Marram Model
• 1976
• For use by individual practitioners as well as organizations
• Pragmatic, most widely used
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Assumptions of Stetler/Marram
• Formal organizations may or may not be involved
• Research provides probabilistic information, not absolutes
• Includes experience and theory
• Lack of knowledge of utilization can inhibit effective use
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Six Phases: Stetler/Marram
• Preparation
• Validation
• Comparative Evaluation– Fit of setting, Feasibility– Substantiating evidence, Current practice
• Decision making
• Translation/Application
• Evaluation
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Research Utilization versus Evidence Based Practice
• Are these the same or different?
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Forms of Research Utilization
• INSTRUMENTAL: concrete application to practice
• CONCEPTUAL: enlightment, changes understanding
• SYMBOLIC: legitimates current practice or position
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What Do You Decide?
• Use
• Consider use
• Delay use
• Forget it
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AHRQ and Clinical Practice Guidelines
• AHCPR established 1989 to enhance quality, appropriateness and effectiveness of health care services
• Guidelines developed between 1990-96
• Each guideline has– full guideline and quick reference for
practitioner – consumer guide
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Guideline Development Process
• Extensive interdisciplinary clinical review of needs, practices, emerging technology
• Comprehensive literature review
• Ranking of evidence quality
• Peer review of guideline drafts
• Pilot review with intended users
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AHRQ Guideline Topics
• Acute pain management
• Alzheimer’s disease
• Benign prostate hyperplasia
• Cancer pain
• Cardiac rehabilitation
• Cataract
• Depression
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Guidelines, cont.
• Heart failure
• Low back problems
• Mammography
• Otitis media
• Post-stroke rehabilitation
• Pressure ulcers
• Sickle cell disease
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Guidelines, cont.
• Smoking cessation
• Unstable angina
• Urinary incontinence
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Oh, oh: Political Problems
No more specific guidelines
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Practice Guidelines as Evidence-based Information
• Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances (IOM, 1990)
• Science based• Explicit, yet flexible• Developed by practitioners• Subject to revision
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Evidence-based Practice Centers (EPCs)
• 12 EPCs established in 1997• Promote evidence-based practice in
everyday care• Develop evidence reports and technology
assessments• AHRQ serves as “science partner” to
improve quality, effectiveness, and appropriateness of clinical care
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Next Iteration
• Evidence-based Practice Centers: Examples– Evaluation of cervical cytology
– Treatment of attention deficit disorder
– Treatment of acute sinusitis
– Pharmacotherapy for alcohol dependence
– Testosterone suppression treatment for prostatic cancer
– Swallowing problems in elderly
– Assessing cost-effectiveness of interventions
– Assessing translation of evidence into practice
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National Guideline Clearinghouse
Agency for Healthcare Research
and Quality
(AHRQ)
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Other Research-Based Guidelines
• CDC– http://www.cdc.gov/ncidod/publicat.htm– Isolation precautions, prevention of IV-related
infections, prevention of nosocomial pneumonia, prevention of spread of VRE, prevention of surgical site infections, personnel health
• Professional Organizations
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The National Guideline Clearinghouse™
• Partnership with AAHP and AMA• Web-based repository for clinical practice
guidelines• Objective is to provide “one stop shopping” for
consumers and providers seeking to access and keep abreast of the many guidelines in use
• Allows comparisons of guidelines with different content and recommendations
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For Utilization Project
• Stetler C. Refinement of the Stetler/Marram model for application of research findings to practice. Nurs Outlook 1994; 42:15-25.
• Stetler C, et al. Enhancing research utilization by clinical nurse specialists. Nurs Clin NA 1995; 30:457-473.
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Other Published Reviews and Recommendations
• Qualitative, non-systematic, narrative– Process is not clear-cut in how literature was
selected
• Systematic
• Meta-analysis