The Online Newsletter for Children's Nurses
e-Edition, Issue 10
Evidence, Research and Quality
Improvement In Clinical Practice
By Betsy Muller, PhD, WHNP-BC
Objectives of this Continuing Education (CE) Program
- Describe the early history of healthcare before the development of scientific inquiry.
- List the elements of evidence-based practice.
- Identify three critical elements of research.
- Identify the purposes of performance improvement in clinical practice.
- Describe sources for evidence to support clinical practice.
- Describe the place of the art of nursing in evidence-based practice.
Nursing is an art and a science. Most nurses are comfortable with the art of caring, the mentorship of other nurses to apply classroom learning at the bedside, and the development of therapeutic relationships. Nurses are less comfortable with the science, the evidence, the measurement of performance, and the acceptance of new ways of doing things. One explanation for this discomfort may be confusion about the following terms: evidence-based practice, research, and performance improvement. The purpose of this continuing education program is to provide concise information about these terms as they are used in clinical nursing, and how they enhance rather than replace the art of nursing.
The Historic Foundations
For most of history, the care of sick people was based on suspicion, religious beliefs, trial and error, and observations of the natural world. However, some of the basic rules of caring for the sick were devised during these early times. Egyptian surgeons performed surgery on the skulls of their patients and saw them heal and continue to live productive lives. Hippocrates, believing that the body was comprised of four humors, nonetheless devised the notions of taking a history, examining the patient, identifying the disease and giving a prognosis. Arabic pharmacists developed methods for quality control of medicines that rival the modern methods.
During the 18th and 19th centuries, science bloomed and much was learned about how the body functioned, how microbes impacted human health, and which treatments led to healing. Yet the adoption of this “early evidence” was slow and sometimes painful. It was many years before physicians routinely washed their hands after the discoveries of Semmelweiss, the 19th century Hungarian physician who discovered that cleaning the hands after autopsy and before visiting newly delivered women would decrease the incidence of childbed fever and death. Unfortunately, as recent national hand hygiene figures indicated, all these years later there continues to be opportunity for improvement.
As late as the mid 20th century, most care delivered to patients was “what we have always done” in nursing. Scientific principles were behind the water temperature of the patient’s daily bath. But there was no research about the advisability of a daily bath for all patients. The nurse in clinical practice did not consider research part of that practice. Rather, research was done by people with graduate degrees who worked in universities or university hospitals. Nurses weren’t even comfortable reading research let alone interpreting it.
By the late 20th century, nurses began to hear managers and supervisors talk about the need for performance improvement projects. The concept of performance improvement (PI) first impressed the business world during the mid 20th century. The Japanese, after World War II, focused on improving the performance of their factories to produce goods and create a vibrant society. This PI process was brought to the United States and became the “hot” way to increase productivity and customer satisfaction. In an effort to improve patient outcomes, PI was adopted in the 1980s by healthcare for use in the clinical area. Nurses would hear about PI projects, but it was often confused with research. Nurses didn’t see the connection between PI and the way nurses did their work at the bedside.
Beginning in the 1990s, clinicians heard another new phrase being promoted by physicians and epidemiologists: “evidence-based practice.” Studies were done to detect which medical practices were effective and which practices actually caused more harm than good, e.g., giving antibiotics to patients with viral infections. Basing practice on evidence was promoted not only as a way to improve patient outcomes, but also as a way to promote confidence in one’s clinical choices.
Today, nurses are expected to practice using evidence, participate in (or consume) research, and applaud PI projects. But there is confusion. How do evidence-based practice, research and PI fit together? Do they fit together? Are they the same or are they different from each other? And how do they improve patient care and increase nursing satisfaction? The remainder of this paper is devoted to simply stating what each entity is and how they all fit together.
The phrase “evidence-based” as applied to clinical practice first appeared in the 1990s. The classic definition used to this day appeared in a 1996 letter to the editor in the British Medical Journal.
Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external evidence from systematic research.
The authors went further to state that the practitioner must seek not just any evidence, but the “best available… systematic” evidence. And that was not the end of the process. The practitioner’s clinical expertise and the patient’s clinical condition and preferences must always be considered.
That sounds easy. To ensure practice is evidence-based, get the evidence, use your expertise, and consider and involve your patient in the choices you make at the bedside. The same could be said for policies that guide clinical practice within a facility. They are evidence-based when the strong, reliable evidence was found and combined with clinical experience and the characteristics of the patient populations. On the other hand, maybe this process is not so easy. Where does all of this strong, systematic evidence come from? That is where the research process comes in.
At its most basic, research is the process of getting answers to questions. During the course of a day of patient care, nurses may ask themselves why they are doing something or what would happen if they tried another process. This is the basis of a clinical nursing research question or problem. How to solve the problem or answer the question requires a process developed over centuries we now call clinical research (or for our practice, clinical nursing research). Research is a systematic, controlled process that evolved from the old “trial and error” process. The first step is to obtain what knowledge already exists about the question. This can be found by reading the research literature. The next step is to devise a design or plan to find the answers. The design focuses on the question while it eliminates outside influences. Subjects are identified who will be part of the design. The subjects may be observed, questioned or undergo a treatment. All of this is rigidly outlined in the design. This care provides the control ensuring confidence in the accuracy of that plan. Next, the researcher carefully chooses the statistics for the research. Statistics enable the researcher to determine how likely it is that the result did not happen by chance. Statistics also tell the researcher if the results can be applied to everyone (usually called generalization) or just to those subjects participating in the research. These initial results (answers to the question) will indicate if the question should be asked again in a different way or if there are other questions that need to be explored. In a nutshell, research is answering relevant questions in a systematic way that eliminates alternatives and increases the likelihood that the results are real. While some research is done to find new knowledge for knowledge’s sake, most research is done so that ultimately the results can be applied in clinical practice.
The classic way (or some would say the gold standard) to answer a question in clinical situations is with a randomized clinical trial. This is often referred to as experimental research. A clinical trial tries to determine what will happen if two groups of people who are alike receive two different treatments. Will one group get better faster? Will there be no difference between the groups? While classic, the experiment is not the only way to do research. There are quasi-experimental studies, observational studies, correlational studies, surveys and qualititative studies. They are all research studies because they are attempting to find or confirm new knowledge. Even if the study was done multiple times, each time it was done with a new group of patients, in a new place, with a slight change to the treatment or intervention, and its underlying goal was to find or confirm new knowledge.
To help clinicians find the results of research and make sense of studies all asking the same question, there is another kind of research: meta-analysis. Meta-analysis is a study combining the results from many studies and reanalyzing them to determine if the overall outcome from these many studies agrees with or differs from the results of each individual study. Systematic reviews of the literature stack up the evidence (pro and con for a particular question) and make an interpretation to help clinicians decide what to do. The Cochrane Library, available for all clinicians and found online through Children’s library, compiles the reviews and meta-analyses that provide clinicians with the strong, systematic evidence to implement research results to improve their patients’ care or change policy with confidence.
The broadest definition of PI is a process or set of tools used to improve performance or productivity in a particular organization or facility. It was originally used by companies to improve their bottom lines. The company would charge a PI team to study a business practice, benchmark performance with other companies, and make a plan for changes that would improve quality. PI was adapted for healthcare and clinical practice, where it was sometimes called quality improvement or total quality management. The goal of PI in clinical practice is to improve patient outcomes. While this can sometimes help the bottom line, that is only a secondary benefit. The primary benefit is an improvement to patient care.
In contrast to research that seeks new knowledge, PI seeks to solve a specific problem in a specific unit or patient group. PI projects include such things as decreasing surgical infection rates and decreasing the length of stay for orthopaedic patients. Similar to the business arena, healthcare PI begins with the identification of a problem to be solved or outcome to be improved. However, where a business would benchmark with other companies, the first task in healthcare is to review the literature and find out what evidence is there supporting a possible solution. If there is a national guideline or standard, the choice of what to do is simple; implement the guideline or standard. Measuring the number of complications before and after initiating the guideline will indicate the amount of improvement resulting from using the guideline. The new practice using the guideline would be evidence-based.
Unfortunately, there may not always be a recognized guideline or standard available to lead to the PI goal. The next source of evidence would be the preponderance of evidence obtained from a systematic review or meta-analysis. If it were strong and consistent, that evidence could be implemented, and the performance, measured again before and after the implementation, would identify success of the process. The clinical practice resulting from the PI process using the material from the systematic review or meta-analysis would be evidence-based.
Finally, there is the situation where there may be some preliminary evidence in the research literature pointing to a new process to improve practice. But if it is just preliminary, if it is scarce, or if it has only been used in special populations, PI may need to move into the research arena. Trying out a practice on patients that is still “experimental” or unproven will require all of the steps and safeguards of research. This would include approval from the institutional review board, a very carefully constructed research plan and informed consent from the patients/parents. Identifying if your project is PI can be tricky. The literature is full of tables comparing and contrasting research and performance improvement. The following is an amalgamation of those tables prepared for this article.
Comparison of Research and Performance Improvement
If you are going to share the results of your facility specific project with people outside your institution or if the patients involved could be identified, check with your IRB for the appropriate precautions and approvals.
This article has demonstrated that evidence-based practice, research and PI are closely related but separate processes. A question about clinical practice leads may go through one or all of the processes depicted below as answers are obtained and put into practice. But the final result of this work is practice supported by strong, systematic evidence. This is what is meant by Evidence-Based Practice (EBP).
The Art of Nursing
This paper began with the definition of EBP and followed with discussion of obtaining and using evidence in practice. There are two other elements to the definition of evidence-based practice: clinical experience and the condition/concerns of the patient. These two fall into the art of nursing. For example, it is the experience of the nurse that first detects the paradoxical reaction to the sedative or the extrapyramidal reaction to metraclopromide. The nurse detects the fear, anxiety and pain interfering with the effectiveness of the evidence-based treatment. The nurse modifies treatment when possible, notifies the provider when necessary, protects the patient always, and promotes the wellbeing of all patients. Nursing is an art and a science; we can be comfortable with both.
To Learn More
For a deeper discussion of evidence-based practice, research and/or performance improvement, the library, under the direction of Cindy Perkins, manager, is an available resource. Reference materials including books and a host of articles in online journals are available. The Nursing Research Council will be launching additional learning modules on these topics, which will include continuing education credit. For more information, refer to iCare, Children’s nursing and clinical portal on the Hospital’s “George Page.” The members of the Nursing Research Council are also available to take your questions. They may not have all the answers, but they can send you in the right direction. You will find the names of the Nursing Research Council members on the iCare page listed under the Nursing Governance section.
Beyea, S. C., & Nicoll, L. H. Is it research or quality improvement? Clinical practice problems. AORN Journal, 1998: 68-117-9.
Beyea, SC., & Slattery, M. J. Evidence-based practice in nursing: A guide to successful implementation. 2006, HCPro, Inc @www.hcpro.com.
Cosco, T., Knopp, A., & Milke, D. (October, 2001) Investigative first steps: Appropriate identification and ethical review of research and quality improvement. Online Journal of Nursing Informatics (OJNI). 11, (3) [Online]. Available at http://ojni.org/11 3/cosco.htm.
Newhouse, R.P., Pettit, J.C., Poe, S., & Rocco, L. The slippery slope: Differentiating between quality improvement and research. The Journal of Nursing Administration 2006:36:211-219
Patient Safety: Current Statistics, Nov. 2011, patientsafetyfocus.com.
Platteborze, L.S., Young-McCaughan, S., King-Letzkus, I., McClinton, A., Halliday, A., & Jefferson, T. C. Performance improvement/research advisory panel: A model for determining whether a project is a performance or quality improvement activity or research. Military Medicine 2010:175(4) 289-291.
Sackett, DL, Rosenberg, WMC, Muir Gray, JA, Haynes, RB, Richardson, WS. Evidence-based medicine: what it is and what it isn’t. British Medical Journal 1996:312:71
Schmidt, N.A., & Brown, J. M. Evidence-based practice for nurses: Appraisal and application of research. 2009, Jones and Bartlett, Sudbury, MA.
Shirey, M. R., Hauck, S. L., Embree, J. L., Kinner, T. J., Schaar, G. L., Phillips, L. A., Ashby, S. R., Swenty, C. F., & McCool, I. A. Showcasing differences between quality improvement, evidence-based practice, and research. The Journal of Continuing Education in Nursing 2011:42 (2) 57-70.
Trueman, Chris. “History of Medicine” History Learning Site. From 2000 ongoing. http:/www.historylearningsite.co.uk.
Process for Earning Continuing Education – 1.0 contact hour is available
Note Continuing Education credit is only available for nurses employed at Children’s Hospital Central California.
- Continuing education is available through November 2012
- Read the continuing education article.
- To complete a brief post test, click on the following link:
- You must achieve a score of 80% to earn credit; a continuing education certificate will be awarded you.
Children’s Hospital Central California is a continuing education provider accredited by the California Board of Registered Nursing (provider number RN: 00316).
1 Trueman, Chris. “History of Medicine” History Learning Site. From 2000 ongoing. http:/www.historylearningsite.co.uk.
2 Patient Safety: Current Statistics, Nov. 2011, patientsafetyfocus.com.
3 Sackett, DL, Rosenberg, WMC, Muir Gray, JA, Haynes, RB, Richardson, WS. Evidence-based medicine: what it is and what it isn’t. British Medical Journal 1996:312:71
4 Beyea, S. C., & Nicoll, L. H. Is it research or quality improvement? Clinical practice problems. AORN Journal, 1998: 68-117-9. and Newhouse, R.P., Pettit, J.C., Poe, S., & Rocco, L. The slippery slope: Differentiating between quality improvement and research. The Journal of Nursing Administration 2006:36:211-219 and Platteborze, L.S., Young-McCaughan, S., King-Letzkus, I., McClinton, A., Halliday, A., & Jefferson, T. C. Performance improvement/research advisory panel: A model for determining whether a project is a performance or quality improvement activity or research. Military Medicine 2010:175(4) 289-291. and Shirey, M. R., Hauck, S. L., Embree, J. L., Kinner, T. J., Schaar, G. L., Phillips, L. A., Ashby, S. R., Swenty, C. F., & McCool, I. A. Showcasing differences between quality improvement, evidence-based practice, and research. The Journal of Continuing Education in Nursing 2011:42 (2) 57-70.
In This Issue
Becoming The BEST
Evidence, Research and Quality Improvement in Clinical Practices
Intentional Care of the Spirit - A Nurse's Gift to Her Community
A Nursing Career - Challenges in Care for Ourselves
Nephrology and Peritoneal Dialysis Clinical Nursing: What Goes On In Here?
Surviving Childhood Cancer
Necessity is the Mother of Re-Invention
Patient Satisfaction Comments