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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

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Nursing Management and Professional Concepts [Internet].

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Chapter 9 – Quality and Evidence-Based Practice

9.1. QUALITY AND EVIDENCE-BASED PRACTICE INTRODUCTION

Learning Objectives

• Examine the role of utilization review and continuous quality improvement

• Describe the role of research in providing evidence-based, quality patient care

• Examine the accreditation process for agencies

• Explain quality patient care based on standards of nursing practice

• Examine the role of government, nursing, and other organizations in developing standards for quality nursing practice

• Analyze how informatics systems promote quality and safety in health care delivery

• Examine the role of the individual nurse in workplace quality improvement processes

• Utilize resources to enhance client care (e.g., evidence-based research, information technology, policies, and procedures)

• Participate in performance improvement projects and quality improvement processes

Florence Nightingale was a pioneer in the evaluation of quality nursing care. She identified the role of a nurse within the health care team and measured patient outcomes to support the value of a nurse. See an example of one of Florence Nightingale’s diagrams comparing the causes of mortality in the Army in Figure 9.1.[1] Over the years nursing theorists and governing agencies have continued the evaluation work of Florence Nightingale by collecting data, using statistics, and creating reports to ensure the best quality care is being delivered to all patients.

Figure 9.1

Figure 9.1

Florence Nightingale’s Diagram of the Causes of Mortality

In previous chapters we discussed how delegation, prioritization, and working as part of an interdisciplinary team all contribute to the delivery of effective and high-quality care. However, a common question by nurses and other health care stakeholders is, “What is the definition of quality health care?” A second question is, “How is quality measured and evaluated in health care to determine if standards are met?” A third related question is, “How do nurses incorporate research and evidence-based practices into their nursing practice?” This chapter will review how quality nursing care is defined, measured, and evaluated and how nurses implement evidence-based practices into their daily nursing practice.

References

1.
"Nightingale-mortality.jpg" by Florence Nightingale is licensed under Public Domain ↵.

9.2. QUALITY CARE

Quality is defined in a variety of ways that impact nursing practice.

ANA Definition of Quality

The American Nurses Association (ANA) defines quality as, “The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.”[1] The phrases in this definition focus on three aspects of quality: services (nursing interventions), desirable outcomes, and consistency with evolving nursing knowledge (evidence-based practice). Alignment of nursing interventions with current evidence-based practice is a key component for quality care.[2] Evidence-based practice (EBP) will be further discussed later in this chapter.

Quality of Practice is one of the ANA’s Standards of Professional Performance. ANA Standards of Professional Performance are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting are expected to perform competently.” See the competencies for the ANA’s Quality of Practice Standard of Professional Performance in the following box.[3]

Competencies of ANA’s Quality of Practice Standard of Professional Performance[4]

• Ensures that nursing practice is safe, effective, efficient, equitable, timely, and person-centered.

• Incorporates evidence into nursing practice to improve outcomes.

• Uses creativity and innovation to enhance nursing care.

• Recommends strategies to improve nursing care quality.

• Collects data to monitor the quality of nursing practice.

• Contributes to efforts to improve health care efficiency.

• Provides critical review and evaluation of policies, procedures, and guidelines to improve the quality of health care.

• Engages in formal and informal peer review processes of the interprofessional team.

• Participates in quality improvement initiatives.

• Collaborates with the interprofessional team to implement quality improvement plans and interventions.

• Documents nursing practice in a manner that supports quality and performance improvement initiatives.

• Recognizes the value of professional and specialty certification.

Reflective Questions

1. What Quality of Practice competencies have you already demonstrated during your nursing education?

2. What Quality of Practice competencies are you most interested in mastering?

3. What questions do you have about the ANA’s Quality of Practice competencies? Where could you find answers to those questions (e.g., instructors, preceptors, health care team members, guidelines, or core measures)?

This chapter will review content related to the competencies of the ANA’s Quality of Practice Standard of Professional Performance. Additional information about peer review is discussed in the “Leadership and Management” chapter, and specialty certification is discussed in the “Preparation for the RN Role” chapter.

Quality and Safety Education for Nurses

The Quality and Safety Education for Nurses (QSEN) project advocates for safe, quality patient care by defining six competencies for prelicensure nursing students: Patient-Centered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, Safety, and Informatics. These competencies are further discussed in the “Advocacy” chapter.

Framework of Quality Health Care

A definition of quality that has historically guided the measurement of quality initiatives in health care systems is based on the framework for improvement originally created by the Institute of Medicine (IOM). The IOM name changed to the National Academy of Medicine in 2015. The IOM framework includes the following six criteria for defining quality health care[5],[6]:

  • Safe: Avoiding harm to patients from the care that is intended to help them.
  • Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (i.e., avoiding underuse and misuse).
  • Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
  • Timely: Reducing waits and sometimes harmful delays for both those who receive and those who provide care.
  • Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
  • Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

This framework continues to guide quality improvement initiatives across America’s health care system. The evidence-based practice (EBP) movement began with the public acknowledgement of unacceptable patient outcomes resulting from a gap between research findings and actual health care practices. For EBP to be successfully adopted and sustained, it must be adopted by nurses and other health care team members, system leaders, and policy makers. Regulations and recognitions are also necessary to promote the adoption of EBP. For example, the Magnet Recognition Program promotes nursing as a leader in catalyzing adoption of EBP and using it as a marker of excellence.[7]

Magnet Recognition Program

The Magnet Recognition Program is an award from the American Nurses Credentialing Center (ANCC) that recognizes organizational commitment to nursing excellence. The award recognizes organizations worldwide where nursing leaders have successfully aligned their nursing strategic goals to improve the organization’s patient outcomes. To nurses, Magnet Recognition means education and development are available through every stage of their career. To patients, it means quality care is delivered by nurses who are supported to be the best that they can be.[8] See Figure 9.2[9] for an image related to the Magnet Recognition Program.

Figure 9.2

Figure 9.2

Magnet Recognition

Reimbursement Models

Quality health care is also defined by value-based reimbursement models used by Medicare, Medicaid, and private insurance companies paying for health services. As discussed in the “Health Care Reimbursement Models” section of the “Health Care Economics” chapter, value-based payment reimbursement models use financial incentives to reward quality health care and positive patient outcomes. For example, Medicare no longer reimburses hospitals to treat patients who acquire certain preventable conditions during their hospital stay, such as pressure injuries or urinary tract infections associated with use of catheters.[10] These reimbursement models directly impact the evidence-based care nurses provide at the bedside and the associated documentation of assessments, interventions, and nursing care plans to ensure quality performance criteria are met.

CMS Quality Initiatives

The Centers for Medicare & Medicaid Services (CMS) establishes quality initiatives that focus on several key quality measures of health care. These quality measures provide a comprehensive understanding and evaluation of the care an organization delivers, as well as patients’ responses to the care provided. These quality measures evaluate many areas of health care, including the following:[11]

  • Health outcomes
  • Clinical processes
  • Patient safety
  • Efficient use of health care resources
  • Care coordination
  • Patient engagement in their own care
  • Patient perceptions of their care

These measures of quality focus on providing the care the patient needs when the patient needs it, in an affordable, safe, effective manner. It also means engaging and involving the patient so they take ownership in managing their care at home.

Visit the CMS What is a Quality Measure web page.

Accreditation

Accreditation is a review process that determines if an agency is meeting the defined standards of quality determined by the accrediting body. The main accrediting organizations for health care are as follows:

  • The Joint Commission
  • National Committee for Quality Assurance
  • American Medical Accreditation Program
  • American Accreditation Healthcare Commission

The standards of quality vary depending on the accrediting organization, but they all share common goals to improve efficiency, equity, and delivery of high-quality care. Two terms commonly associated with accreditation that are directly related to quality nursing care are core measures and patient safety goals.

Core Measures

Core measures are national standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes. Core measure compliance reports show how often a hospital successfully provides recommended treatment for certain medical conditions. In the United States, hospitals must report their compliance with core measures to The Joint Commission, CMS, and other agencies.[12]

In November 2003, The Joint Commission and CMS began work to align common core measures so they are identical. This work resulted in the creation of one common set of measures known as the Specifications Manual for National Hospital Inpatient Quality Measures. These core measures are used by both organizations to improve the health care delivery process. Examples of core measures include guidelines regarding immunizations, tobacco treatment, substance use, hip and knee replacements, cardiac care, strokes, treatment of high blood pressure, and the use of high-risk medications in the elderly. Nurses must be aware of core measures and ensure the care they provide aligns with these recommendations.[13]

Read more about the National Hospital Inpatient Quality Measures.

Patient Safety Goals

Patient safety goals are guidelines specific to organizations accredited by The Joint Commission that focus on health care safety problems and ways to solve them. The National Patient Safety Goals (NPSG) were first established in 2003 and are updated annually to address areas of national concern related to patient safety, as well as to promote high-quality care. The NPSG provide guidance for specific health care settings, including hospitals, ambulatory clinics, behavioral health, critical access hospitals, home care, laboratory, skilled nursing care, and surgery.

The following goals are some examples of NPSG for hospitals[14]:

  • Identify patients correctly
  • Improve staff communication
  • Use medicines safely
  • Use alarms safely
  • Prevent infection
  • Identify patient safety risks
  • Prevent mistakes in surgery

Nurses must be aware of the current NPSG for their health care setting, implement appropriate interventions, and document their assessments and interventions. Documentation in the electronic medical record is primarily used as evidence that an organization is meeting these goals.

Read the current agency-specific National Patient Safety Goals.

References

1.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
2.
Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), manuscript 4. https://ojin​.nursingworld​.org/MainMenuCategories​/ANAMarketplace​/ANAPeriodicals/OJIN​/TableofContents/Vol-18-2013​/No2-May-2013​/Impact-of-Evidence-Based-Practice​.html ↵. [PubMed: 23758422]
3.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
4.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
5.
Agency for Healthcare Research & Quality. (2018, November). Six domains of health care quality. https://www​.ahrq.gov​/talkingquality/measures/six-domains​.html ↵.
6.
Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://pubmed​.ncbi.nlm​.nih.gov/25057539/ ↵. [PubMed: 25057539]
7.
Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), manuscript 4. https://ojin​.nursingworld​.org/MainMenuCategories​/ANAMarketplace​/ANAPeriodicals/OJIN​/TableofContents/Vol-18-2013​/No2-May-2013​/Impact-of-Evidence-Based-Practice​.html ↵. [PubMed: 23758422]
8.
American Nurses Credentialing Center. (n.d.). ANCC magnet recognition program. https://www​.nursingworld​.org/organizational-programs/magnet/ ↵.
9.
10.
James, J. (2012, October 11). Pay-for-performance. Health Affairs. https://www​.healthaffairs​.org/do/10.1377/hpb20121011​.90233/full/ ↵.
11.
12.
13.
14.
The Joint Commission. (2022). 2022 national patient safety goals. https://www​.jointcommission​.org/standards​/national-patient-safety-goals/ ↵.

9.3. MEASURING AND IMPROVING QUALITY

Now that we have discussed the various ways that quality health care is defined, let’s discuss how quality care is measured, evaluated, and improved.

Utilization Review

Thinking back to value-based reimbursement models discussed in the “Health Care Economics” chapter, recall how health care agencies are reimbursed from Medicare, Medicaid, and private insurance based on their quality performance measures. A utilization review is an investigation of health care services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering unnecessary or inefficient expenditures for proper treatment. Utilization review also allows organizations to objectively measure how their health care services and resources are being used to best meet their patients’ needs. Information from patients’ medical records is analyzed, along with patient demographics, to evaluate resource allocation, efficiency, and quality of health promotion initiatives.[1] See Figure 9.3[2] for an illustration of utilization review related to costs.

Figure 9.3

Figure 9.3

Utilization Review

Using Informatics to Promote Quality

Utilization review relies on the collection of meaningful data from health records to determine if quality metrics are being met. Informatics refers to using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.[3] Informatics allows members of the health care team to share, store, and analyze health-related information. Nurses have an important role in informatics. Nursing informatics is the science and practice of integrating nursing knowledge with information and communication technologies to promote the health of people, families, and communities worldwide.[4] It is a nursing specialty with certification available from the ANCC. See Figure 9.4[5] for an artistic rendition of informatics.

Figure 9.4

Figure 9.4

Informatics

These are several benefits of using informatics in health care[6]:

  • Improvement of Patient Safety: Informatics allows for up-to-date information sharing by both the patient and members of the health care team. Using informatics can help to reduce the occurrence of medication errors, as well as monitor patient side effects and overall health status. For example, barcode scanning has reduced medication errors by ensuring the correct dose is administered to the correct patient at the correct time.
  • Reduction of Delays in Care: Some health care informatics systems allow for direct communication between health care team members and patients. The ability to ask and answer questions without needing to schedule an office appointment promotes the ability for care to be delivered efficiently in a cost-effective manner.
  • Reduction of Waste: The use of informatics to share information between care team members reduces waste associated with duplication of tests or exams when more than one provider is on the care team. Additionally, patients can request their records be shared with health providers from other health organizations, which reduces duplication and unnecessary spending across the nation.
  • Promotion of Patient-Centered Care: Many informatics systems have “patient portal” options where the patient and/or designated personnel are able to be active participants in the care planning and health promotion processes. Informatics offers an inclusive environment for patients to communicate and share directly with their care team regardless of physical location and timing.
  • Support of Quality Improvement: The continuous process of quality improvement requires the ability to collect and analyze data in a systematic and reliable manner. Using informatics provides members of the health care team a secure place to store data, as well as the ability to review in a timely manner.

Quality Indicators

The National Database of Nursing Quality Indicators (NDNQI) was developed as a national nursing database used to evaluate quality in nursing care. This database was purchased by Press Ganey in 2014. In collaboration with the American Nursing Association (ANA), the original NDNQI database established nurse-sensitive quality indicators such as these[7]:

  • Nursing Care Hours Per Patient Day
  • Hospital-Acquired Pressure Injuries
  • RN Job Satisfaction

Nurses use quality indicators to support practice changes with evidence directly related to improved patient outcomes.

Read about current quality measures promoting clinical excellence at the Press Ganey website.

Quality Improvement

Quality Improvement (QI) is a systematic process using measurable data to improve health care services and the overall health status of patients.[8] QI is one of the competencies of the Quality and Safety Education (QSEN) project and defined as, “using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.”[9]

The overall goal of the QI process is to improve the quality and safety of health care. The process of quality improvement is very similar to the Nursing Process, but its purpose is to answer these three main questions:

  • What are we trying to accomplish?
  • How will we know if a change is an improvement?
  • What changes can we make that will result in an improvement?

See Figure 9.5[10] for an illustration of the Quality Improvement Process.

Figure 9.5

Figure 9.5

Quality Improvement Process

To answer these questions, QI is a continuous process in which a project is planned, interventions are implemented, data is collected, results are studied, and outcomes are evaluated. The process is repeated after additional planning. During the QI process, four key steps are used to evaluate current patient care and determine if changes are needed. These components are referred to as Plan, Do, Study, and Act:

  • Plan: The first step in the QI process is to identify what you will be testing or focusing on and what will be measured. Similar to the Nursing Process where subjective and objective data are collected, the nurse determines what data will be needed during the QI process. The nurse also determines a timeline for the QI project, such as one year, including a specific framework for when data is collected and when it will be reviewed. For example, fall rates will decrease 10% in one year.
  • Do: After the plan is determined, the nurse works with a health care team to implement the project and ensure data collection occurs.
  • Study: During this phase, the nurse works with the health care team to review and analyze the data that was collected and determine if the outcomes were achieved or not.
  • Act: In the fourth step of the QI process, the team discusses the outcomes. In this step the team identifies barriers, strengths, and weaknesses and then decides if additional changes are needed in nursing practice. The QI process is continuous, so the QI team uses outcome findings to continue the process of Plan, Do, Study, and Act to ensure safe, quality patient care.

See Figure 9.6[11] for an illustration comparing the QI process to the Nursing Process.

Figure 9.6

Figure 9.6

Comparison of the QI Process and the Nursing Process (Source: Amy Tyznik, MPTC)

It is important to note that quality improvement is different from nursing research. QI evaluates processes in place and determines if changes are needed, whereas the goal of research is to identify new innovations in nursing practice.[12]

References

1.
Institute of Medicine (US) Committee on Utilization Management by Third Parties, Gray, B. H., & Field, M. J., (Eds.). (1989). Controlling costs and changing patient care? The role of utilization management. National Academies Press. https://www​.ncbi.nlm​.nih.gov/books/NBK235000 ↵. [PubMed: 25144100]
2.
3.
QSEN Institute. (n.d.). QSEN competencies: Quality improvement (QI). https://qsen​.org/competencies​/pre-licensure-ksas​/#quality_improvement ↵.
4.
5.
6.
Otokiti, A. (2019). Using informatics to improve healthcare quality. International Journal of Health Care Qual Assurance , 32(2), 425-430.  ↵ 10.1108/ijhcqa-03-2018-0062. [PubMed: 31017059] [CrossRef]
7.
Montalvo, I. (2007). The National Database of Nursing Quality Indicators (NDNQI). The Online Journal of Issues in Nursing , 12(3). https://ojin​.nursingworld​.org/MainMenuCategories​/ANAMarketplace​/ANAPeriodicals/OJIN​/TableofContents/Volume122007​/No3Sept07​/NursingQualityIndicators.aspx ↵. [PubMed: 21800926]
8.
Study.com. (n.d.). What is economics? - Definition, history, timeline & importance [Video]. https://study​.com/academy​/lesson/what-is-economics-definition-history-timeline-importance.html ↵.
9.
QSEN Institute. (n.d.). QSEN competencies: Quality improvement (QI). https://qsen​.org/competencies​/pre-licensure-ksas​/#quality_improvement ↵.
10.
11.
“Comparison_QI Process_Nursing Process.jpg” by Amy Tyznik, MPTC for Open RN is licensed under CC BY 4.0 ↵.
12.
Agency for Healthcare Research and Quality. (2013, May). Module 4. Approaches to quality improvement. Practice facilitation handbook. https://www​.ahrq.gov​/ncepcr/tools/pf-handbook/mod4.html ↵.

9.4. EVIDENCE-BASED PRACTICE AND RESEARCH

There are many ties between safe, quality patient-centered care; evidence-based practice; research; and quality improvement. These concepts fall under the umbrella term “scholarly inquiry.” All nurses should be involved in scholarly inquiry related to their nursing practice, no matter what agency they work. The American Nursing Association (ANA) Standard of Professional Performance called Scholarly Inquiry lists competencies related to incorporating evidence-based practice and research for all nurses. See the following box for a list of these competencies.[1]

Competencies of ANA’s Scholarly Inquiry Standard of Professional Performance[2]

• Identifies questions in the health care or practice setting that can be answered by scholarly inquiry.

• Uses current evidence-based knowledge, combined with clinical expertise and health care consumer values and preferences, to guide practice in all settings.

• Participates in the formulation of evidence-based practice.

• Uses evidence to expand knowledge, skills, abilities, and judgement; to enhance role performance; and to increase knowledge of professional issues for themselves and others.

• Shares peer-reviewed, evidence-based findings with colleagues to integrate knowledge into nursing practice.

• Incorporates evidence and nursing research when initiating changes and improving quality in nursing practice.

• Articulates the value of research and scholarly inquiry and their application to one’s practice and health care setting.

• Promotes ethical principles of research in practice and the health care setting.

• Reviews nursing research for application in practice and the health care setting.

Reflective Questions

1. What Scholarly Inquiry competencies have you already demonstrated during your nursing education?

2. What Scholarly Inquiry competencies are you most interested in mastering?

3. What questions do you have about the ANA’s Scholarly Inquiry competencies?

Nursing practice should be based on solid evidence that guides care and ensures quality. Evidence-based practice (EBP) is the foundation for providing effective and efficient health care that promotes improved patient outcomes. Evidence-based practice is defined by the American Nurses Association as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.”[3] See Figure 9.7[4] for an illustration of evidence-based practice.

Figure 9.7

Figure 9.7

Evidence-based Practice

Evidence-based practice is the foundation nurses rely on to ensure their interventions, policies, and procedures are based on data supporting positive patient outcomes. EBP relies on scholarly research that generates new nursing knowledge, as well as quality improvement processes that review patient outcomes resulting from current nursing practice, to continually improve quality care. EBP encourages health care team members to incorporate new research findings into their practice, referred to as translating evidence into practice. Nurses must recognize the partnership between EBP and research; EBP cannot exist without continual scholarly research, and research requires nurses to evaluate research findings and incorporate them into their practice.[5]

Read examples of nursing evidence-based projects from Johns Hopkins.

Newly graduated nurses may become immediately involved with evidence-based practice and quality improvement processes. The Quality and Safety Education (QSEN) project further elaborates on evidence-based practice for entry-level nurses with the definition of EBP as, “integrating best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.” See Table 9.4 for the knowledge, skills, and attitudes associated with the QSEN competency of evidence-based practice for entry-level nurses.

Table 9.4

QSEN: Knowledge, Skills, and Attitudes Associated With Evidence-Based Practice

KnowledgeSkillsAttitudes
Demonstrate knowledge of basic scientific methods and processes.
Describe EBP to include the components of research evidence, clinical expertise, and patient/family values.		Participate effectively in appropriate data collection and other research activities.
Adhere to Institutional Review Board (IRB) guidelines.
Base individualized care plan on patient values, clinical expertise, and evidence.		Appreciate strengths and weaknesses of scientific bases for practice.
Value the need for ethical conduct of research and quality improvement.
Value the concept of EBP as integral to determining best clinical practice.
Differentiate clinical opinion from research and evidence summaries.
Describe reliable sources for locating evidence reports and clinical practice guidelines.		Read original research and evidence reports related to area of practice.
Locate evidence reports related to clinical practice topics and guidelines.		Appreciate the importance of regularly reading relevant professional journals.
Explain the role of evidence in determining best clinical practice.
Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patient-centered care.		Participate in structuring the work environment to facilitate integration of new evidence into standards of practice.
Question rationale for routine approaches to care that result in less-than-desired outcomes or adverse events.		Value the need for continuous improvement in clinical practice based on new knowledge.
Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences.Consult with clinical experts before deciding to deviate from evidence-based protocolsAcknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices.

Reflective Questions: Read through the knowledge, skills, and attitudes in Table 9.4.

1. How are you currently integrating evidence-based practice when providing patient care?

2. Where do you find information on current evidence-based practice?

3. Have you witnessed any routine approaches to care that resulted in less-than-desired outcomes or adverse events?

4. What else would you like to learn about evidence-based nursing practice?

Keeping Current on Evidence-Based Practices

Health care is constantly evolving with new technologies and new evidence-based practices. Nurses must dedicate themselves to being lifelong learners. After graduating from nursing school, it is important to remain current on evidence-based practices. Many employers subscribe to electronic evidence-based clinical tools that nurses and other health care team members can access at the bedside. Nurses also independently stay up-to-date on current evidence-based practice by reading nursing journals; attending national, state, and local nursing conferences; and completing continuing education courses. See the box below for examples of ways to remain current on evidence-based practices.

Research

Earlier in this chapter we discussed the process of quality improvement and the manner in which it is used to evaluate current nursing practice by determining where gaps exist and what improvements can be made. Nursing research is a different process than QI. The American Nurses Association (ANA) defines nursing research as, “Systematic inquiry designed to develop knowledge about issues of importance to the nursing professions.”[6] The purpose of nursing research is to advance nursing practice through the discovery of new information. It is also used to provide scholarly evidence regarding improved patient outcomes resulting from evidence-based nursing interventions.

Nursing research is guided by a systematic, scientific approach. Research consists of reviewing current literature for recurring themes and evidence, defining terms and current concepts, defining the population of interest for the research study, developing or identifying tools for collecting data, collecting and analyzing the data, and making recommendations for nursing practice. As you can see, the scholarly process of nursing research is more complex than the Plan, Do, Study, Act process of QI and typically requires more time and resources to complete.[7]

Nurse researchers often use the PICOT format to organize the overall goals of the research project. The PICOT mnemonic assists nurses in answering the clinical question to be studied.[8] See Figure 9.8.[9] for an image of PICOT.

P: Population/Problem: Who are the patients that will be studied (e.g., age, race, gender, disease, or health status, etc.) and what problem is being addressed (e.g., mortality, morbidity, compliance, satisfaction, etc.)?

I: Intervention: What is the specific intervention to be implemented with the research population (e.g., therapy, education, medication, etc.)?

C: Comparison: What is the alternative intervention that will be used to compare to the treatment intervention (e.g., placebo, no intervention, different medication, etc.)?

O: Outcome: What will be measured and how will it be measured and with what identified goal (e.g., fewer symptoms, increased satisfaction, reduced mortality, etc.)?

T: Time Frame: How long will the interventions be implemented and data collected for this research?

After the researcher has completed the PICOT question, these additional questions should also be considered to protect patients’ rights and reduce the potential for ethical conflicts:

  • Was the study approved by the Institutional Review Board (IRB)? The IRB, also known as an independent ethics committee, reviews research studies to protect the rights and welfare of participants.[10] Read more about ethics related to research in the “Ethical Practice” chapter.
  • Were the participants protected? Researchers have the responsibility to protect human rights, uphold HIPAA, and respect the personal values of the participants.
  • Did the benefits of the intervention outweigh the risk(s)? Researchers have the responsibility to identify if there is a possibility for increased harm to the patients because of the research project.
  • Were informed consents obtained? All research participants must provide written informed consent before a study can begin. Researchers must ensure the participants were fully informed of the study, provided risks and benefits, and allowed to exit the study at any time.
  • Were vulnerable populations protected? Populations of study that include infants, minorities, children, elderly, socioeconomically disadvantaged, prisoners, etc., are considered vulnerable populations, and researchers must ensure their rights and safety are accounted for.

After the nurse researcher confirms participants’ rights are protected and has established a PICOT question, the next step is to design the research study and review existing research. Research designs are categorized by the type of data that is collected and reviewed. See Figure 9.9[11] for an illustration of different types of research. The three basic types of nursing research are quantitative studies, qualitative studies, and meta-analyses.

Figure 9.9

Figure 9.9

Research

  • Quantitative Studies: These studies provide objective data by using number values to explain outcomes. Researchers can use statistical analysis to determine the strength of the findings, as well as identify correlations.
  • Qualitative Studies: These studies provide subjective data, often focusing on the perception or experience of the participants. Data is collected through observations and open-ended questions and is often referred to as experimental data. Data is interpreted by recurring themes in participants’ views and observations.
  • Meta-Analyses: A meta-analysis, also referred to as a “systematic review,” compares the results of independent research studies asking similar research questions. A meta-analysis often collects both quantitative and qualitative data to provide a well-rounded evaluation by providing both objective and subjective outcomes. This research design often requires more time and resources, but it also promotes consistency and reliability through the identification of common themes.

Nurses must understand the types of research designs to accurately understand and apply the research findings. Additionally, only research from peer-reviewed scholarly journals should be used. Scholarly journals use a process called “peer review” to ensure high quality. An article that is peer reviewed has been reviewed independently by at least two other academic experts in the same field as the author(s) to ensure accuracy.

Nurses must also be aware of the difference between primary and secondary sources of scholarly evidence. A primary source is the original study or report of an experiment or clinical problem. The evidence is typically written and published by the individual(s) conducting the research and includes a literature review, description of the research design, statistical analysis of the data, and discussion regarding the implications of the results.

A secondary source is written by an author who gathers existing data provided from research completed by another individual. A secondary source analyzes and reports on findings from other research projects and may interpret findings or draw conclusions. In nursing research secondary sources of evidence are typically published as a systematic review and meta-analysis.

View QUT Library’s Primary vs. secondary sources YouTube video. [12]

By understanding these basic research concepts, nurses can accurately implement current evidence-based practice based on continually evolving nursing research.

References

1.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
2.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
3.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
4.
"Flowchart-sm​.png” by Bates98 is licensed under CC BY_SA 4.0 ↵.
5.
Chien, L. Y. (2019). Evidence-based practice and nursing research. The Journal of Nursing Research: JNR , 27(4), e29.  ↵ 10.1097/jnr.0000000000000346 . [PMC free article: PMC6641093] [PubMed: 31313747] [CrossRef]
6.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
7.
American Association of Colleges of Nursing. (2006). Nursing research. https://www​.aacnnursing​.org/News-Information​/Position-Statements-White-Papers​/Nursing-Research ↵.
8.
Lansing Community College Library. (2021, August 27). Nursing: PICOT. https://libguides​.lcc​.edu/c.php?g=167860&p=6198388 ↵.
9.
"PICOT.png" by Kim Ernstmeyer for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
10.
U. S. Food & Drug Administration. (2019, April 18). Institutional review boards frequently asked questions: Guidance for institutional review boards and clinical investigators. https://www​.fda.gov/regulatory-information​/search-fda-guidance-documents​/institutional-review-boards-frequently-asked-questions ↵.
11.
12.
QUT Library. (2020, November 22). Primary vs. secondary sources. [Video]. YouTube. All rights reserved. https://youtu​.be/FZRxYfWYEBI ↵.

9.5. SPOTLIGHT APPLICATION

Joanne is a newly graduated nurse working on a general medical floor in a large urban teaching hospital. She is typically assigned between four and six patients during her shift depending on the acuity mix. Many of her patients are direct admit patients or are transferred from the emergency department. Joanne has recently noticed a significant delay on weekend shifts with room turnover and new patient admittance.

Joanne voiced her concerns regarding the delays to her unit manager. Her manager agreed that room turnover delays on the weekend have significantly increased in recent months. She reported that she will investigate the delays further. A few weeks pass and Joanne’s manager reports back that there have been staff reductions in the organization’s environmental services staff on the weekend shifts. As a result, room cleaning has been delayed significantly. Joanne’s manager has voiced her concerns regarding the delays, but administration has been reluctant to hire additional staff. Joanne and her manager both feel strongly that investment in staff is needed.

Reflective Questions

1. What strategies might Joanne and her manager utilize to reflect the significance of these staff shortages?

2. How might they gather and present information to demonstrate the need for additional environmental services personnel?

3. What stakeholders would be important to engage in this discussion?

4. Create a PICOT question for this scenario.

When considering the impact of care delays in a health care organization, it is important to gather data to substantiate the significance of delayed care. Joanne and her manager might begin to look at organizational throughput or transfer data to determine how long patients are being held in emergency rooms or other settings during the weekend shifts compared to weekday shifts. Additionally, it would be important for the organization to determine if these delayed admits impeded the ability of the emergency department to accept patients and if the organization was subsequently placed on patient divert due to an inability to care for patients in the emergency room setting. Engaging house supervisors, charge nurses, informatics specialists, etc., may be helpful in determining the significance of the delay and potential quality implications. An example PICOT question to help examine this scenario may be structured as: What is the impact of one additional environmental services FTE compared to existing staffing patterns on organizational throughput times over a three-month period?

9.6. LEARNING ACTIVITIES

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IX. GLOSSARY

Accreditation

A review process to determine if an agency meets the defined standards of quality determined by the accrediting body.

ANA Standards of Professional Practice

Authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting are expected to perform competently.

Core measures

National standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes.

Evidence-Based Practice (EBP)

A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.[1]

Informatics

Using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.[2] This allows members of the health care team to share, store, and analyze health-related information.

Meta-analysis

A type of nursing research (also referred to as a “systematic review”) that compares the results of independent research studies asking similar research questions. This research often collects both quantitative and qualitative data to provide a well-rounded evaluation by providing both objective and subjective outcomes.

Nursing informatics

The science and practice integrating nursing, its information and knowledge, with information and communication technologies to promote the health of people, families, and communities worldwide.

Nursing research

The systematic inquiry designed to develop knowledge about issues of importance to the nursing profession.[3] The purpose of nursing research is to advance nursing practice through the discovery of new information. It is also used to provide scholarly evidence regarding improved patient outcomes resulting from nursing interventions.

Patient safety goals

Guidelines specific to organizations accredited by The Joint Commission that focus on problems in health care safety and ways to solve them.

Peer-reviewed

Scholarly journal articles that have been reviewed independently by at least two other academic experts in the same field as the author(s) to ensure accuracy and quality.

Primary source

An original study or report of an experiment or clinical problem. The evidence is typically written and published by the individual(s) conducting the research and includes a literature review, description of the research design, statistical analysis of the data, and discussion regarding the implications of the results.

Quality

The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.

Quality Improvement (QI)

A systematic process using measurable data to improve health care services and the overall health status of patients. The QI process includes the steps of Plan, Do, Study, and Act.

Qualitative research

A type of study that provides subjective data, often focusing on the perception or experience of the participants. Data is collected through observations and open-ended questions and often referred to as experimental data. Data is interpreted by developing themes in participants’ views and observations.

Quantitative research

A type of study that provides objective data by using number values to explain outcomes. Researchers can use statistical analysis to determine strength of the findings, as well as identify correlations.

Secondary source

Evidence is written by an author who gathers existing data provided from research completed by another individual. This type of source analyzes and reports on findings from other research projects and may interpret findings or draw conclusions. In nursing research these sources are typically published as a systematic review and meta-analysis.

Utilization review

An investigation by insurance agencies and other health care funders on services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering things that are unnecessary for proper treatment or are inefficient. This review also allows organizations to objectively measure how effectively health care services and resources are being used to best meet their patients’ needs.

References

1.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
2.
QSEN Institute. (n.d.). QSEN competencies: Quality improvement (QI). https://qsen​.org/competencies​/pre-licensure-ksas​/#quality_improvement ↵.
3.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
Copyright Notice

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.

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