Let research feed your practice
EBP building starts with a deep investigation of the literature
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By Heather Stringer
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EDITOR'S NOTE: Heather Stringer is a freelance writer.
Donnya Mogensen, MS, RN-BC, was coordinating the new graduate nurse residency program at Children’s Hospital Colorado when she discovered that many of the nurses — and their more seasoned mentors — were struggling to grasp the concept of evidence-based practice.
“It seemed like nurses were diving into quality improvement projects without looking at the literature to figure out the best practice first,” Mogensen said. “This is often why quality improvement initiatives fail.” She shared her observation with Diedre Bricker, MSN, RN, CRRN, an innovations and outcomes specialist at the hospital, who agreed. “Evidence-based practice is a buzz word that means different things to different people,” said Bricker. “When I was in nursing school, it meant going through a long, painstaking process of critiquing one study, which is not accurate.” Other nurses believed it was selecting articles that supported a preconceived idea of what needed to change, she said. To better understand how to use existing research to change practice at the bedside, the two nurses attended a week-long training at the Center for Transdisciplinary Evidence-Based Practice at Ohio State University in 2014. There they learned a straightforward method for evaluating literature, communicating the findings to others and implementing change. Convinced that other caregivers needed this type of training, they asked hospital leaders to consider bringing the CTEP training to the hospital. In 2016, 100 staff members completed the training and now serve as evidence-based practice mentors.
The process of evidence-based change may start when a nurse reads an interesting article, or has an idea about how to improve outcomes. This can generate ideas for a topic that requires further research.

At Children’s Colorado, this is the time to find a mentor who is familiar with CTEP and can confirm that deeper investigation would be valuable to the unit and larger organization. Next, the nurse can gather a team of people who would be affected by the potential change in practice. For example, if a nurse wanted to explore which thermometers are the most accurate, the team could include representatives from the ED, inpatient care and ambulatory care, Bricker said. The next step is forming a question that will guide the literature search about the topic. This is known as the PICO question, which stands for Population, Intervention, Comparison and Outcomes.
For example, Bricker recently explored this question: In healthcare providers, how does a journal club compared with no journal club affect research utilization? For this topic, the population was healthcare providers, the intervention was a journal club, the comparison was a journal club versus no journal club, and the outcome was the use of research in clinical practice. Another question in this format could be: In pediatrics, how does flushing with saline versus flushing with heparin affect IV patency?
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CO-514740624quote-mark
It seemed like nurses were diving into quality improvement projects without looking at the literature to figure out the best practice first.”
— Donnya Mogensen, RN
Demystifying literature
One of the latest evidence-based projects at Children’s Colorado involved bedside shift reports. A nurse-led team studied the literature to compare outcomes for shift reporting at the nursing station versus in the patients’ rooms.

“The evidence was overwhelming that we needed to do shift reporting with the patient and family involved,” Bricker said. “It improves communications and allows nurses to catch mistakes because everyone is in the room.”

The new shift reporting procedure started hospital-wide on January 1.
In another project, a Children’s Colorado nurse decided to pursue further research after she read articles about a strategy to decrease central line infections. She gathered a team to study the literature about using alcohol-impregnated caps to reduce catheter-related bloodstream infections.

The evidence strongly supported the benefits of these caps, and she presented her findings to the hospital’s Central Line Catheter Committee. The committee talked to administrators to get approval to trial the products, and the trial was successful. In the summer of 2016, the hospital adopted the new caps as the standard. Since then, the infection rate has dropped 30%, according to the hospital’s quality department. “Now the staff is using literature to have more control over their practice, which ultimately allows them to provide better care for their patients,” Mogensen said.
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The research transformation
Nurse has idea for improving practice.
Nurse and mentor together confirm value of deeper literature investigation.
Nurse gathers (possibly multispecialty) team of those who may be affected by outcome of research.
Forms PICO question based on background search.
Conducts comprehensive search of literature.
Team selects pertinent and relevant articles.
Team critically appraises each study.
Findings are combined into synthesis table.
Decision is made on whether there is overwhelming evidence to implement change. If yes, a small trial is started on the unit, and eventually the change is implemented throughout the hospital.
If evidence does not support change, team can consider launching its own research project.
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The next step is conducting a comprehensive search of the literature using databases such as PubMed, Medline and Cochrane. Medical librarians can be valuable resources for this step of the process. The search could generate dozens of articles, and team members can scan the studies to decide which ones are most relevant based on criteria like how recently they were published and whether the study is in English.

After dividing the remaining articles among team members, they critically appraise each study by looking at details such as the sample size, how many participants dropped out, how the data were analyzed and whether the results reflect the study’s original question.

Finally, the team members combine their findings from each study in a shared template known as the synthesis table, which can be accessed via the hospital’s intranet, Bricker said. “If the team finds overwhelming evidence that a change should be implemented, then they may start by doing a small trial on a unit, and then ramp up to the entire hospital if this goes well,” Bricker said.

Sometimes team members may find that there is scant evidence about their topic, which may be a good reason to consider launching a research project of their own. In this case, they would seek approval through the clinical inquiry council and mentorship from a nurse researcher.
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