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Nursing Management:
doi: 10.1097/01.NUMA.0000387083.21113.09
Feature: CE Connection

The evidence that isn't... Interpreting research

Hader, Richard PhD, NE-BC, RN, CHE, CPHQ, FAAN

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Editor-in-Chief

In addition to serving as editor in-chief of Nursing Management, Richard Hader is the senior vice president and chief nurse officer of Meridian Health, N.J.

What's hindering our progression from folklore to fact?

The author has disclosed that he has no financial relationships related to this article.

When patients seek a healthcare practitioner for services, they believe that the delivered care is based on proven science. But reality is far from patient perception. In fact, most care is still based on anecdote, not evidence.

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Nursing and medical practice is in constant flux. Many of us can recall when pneumonia was an acceptable complication of ventilated patients, or when it was clinically appropriate to recommend that patients spend 7 days in bed with limited mobility post myocardial infarction. Translating science into practice by implementing clinically proven "care bundles" has nearly eradicated the chance of a patient developing pneumonia, despite long-term ventilator therapy, and myocardial infarction patients are now encouraged to ambulate quickly.1 As an industry, we must continue to challenge the norm, question our historical practice, and find new therapies to improve care while reducing unnecessary costs.

Economic pressures brought about by governmentally-led healthcare reform, the acceleration of consumer expectations following the release of publicly reported clinical outcomes, and the emergence of national not-for-profit organizations have ignited interest by providers to ensure that care delivery is based on scientific evidence that's patient focused, interdisciplinary, and cost-effective. To achieve this, there must be a radical paradigm shift from practicing based on folklore and tradition to empirical evidence. Failure to rectify alterations in practice that aren't evidence based will result in economic collapse and threaten access to healthcare for many communities.

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Economic imperative

It's estimated that the cost of healthcare delivery in the United States is $2.3 trillion a year. This amount has tripled in the last two decades, and the financial infrastructure can't sustain this rapidly growing expense. Over 50% of the cost is associated with hospital stays and physician fees. It's evident that a change in practice patterns must be facilitated or the current health system will collapse.2

Due to dwindling healthcare profits, about 50% of U.S. hospitals are operating in the red.3 Facilities continue to suffer from unprofitable growth. Although many healthcare markets aren't experiencing a volume decline, they're seeing increased patient acuity, which yields minimal—if any—profit. The cause? Many chronic conditions are poorly reimbursed by federal and commercial payers and place an inordinate burden on hospitals and healthcare organizations to provide quality care in the most cost-effective manner.

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Policy imperative

Healthcare reform has brought an additional spotlight on the need to provide improved care at a lower cost. As part of the ongoing healthcare reform, legislation passed by the U.S. Congress will provide most Americans with health insurance, holding providers (hospitals and other healthcare organizations) and payers (insurance companies) more accountable for the quality of delivered care.

Healthcare reform requires that there be a more integrated and continuous level of care provided to patients, rather than the traditional approach of diagnosing and treating an acute episode. Many healthcare providers will be evaluating their readiness to provide an integrated delivery system—known as an accountable care organization—that focuses on a continuum of care paid through a bundle payment system.

Healthcare providers will need to develop better tools of communication between personnel and throughout the continuum of care to ensure that the appropriate healthcare information is shared and used. Through greater use of electronic healthcare records, which often include decision-support applications, providers will be required to follow established protocols that are evidence based and patient focused, while still allowing for critical analysis by the healthcare practitioner. Outcome measures will be more easily tracked and trended, which will allow for an improved mechanism to determine whether treatment is productive, efficient, and collaborative.

This information will provide a foundation to stimulate the growth of knowledge and provide healthcare researchers a plethora of both data and information to determine effectiveness of care.

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Consumer imperative

Consumer expectations for quality patient care and services have increased dramatically over the past decade. Public reporting of quality data is easily accessible and is promoted by healthcare consumer watchdog groups. Educated consumers are requesting data to assist with making informed, reliable decisions. Just as consumers look for methods to procure value in products and services they purchase, they seek organizations and individual providers with demonstrated consistent quality performance in delivering healthcare.

Increased competition for consumer revenue has forced healthcare organizations to cater to the service desires of the community. Hospital leaders have engaged guest service consultants to transform their organizations from a once dreaded sterile facility into one filled with traditional hotel accommodations, complete with grand pianos in the lobbies, room service amenities, and spa offerings such as massages and manicures.

Consumers are expecting care that's delivered in an environment that's both pleasing and safe. This has prompted healthcare architects to retool the design of traditionally unremarkable buildings to enhance function and healing, focusing on sound attenuation, increased patient visualization, access to natural light, and privacy measures.

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A changed business model

Historically, hospitals have responded to economic strife by arbitrarily cutting an across-the-board percentage of staff, resulting in fragmented care and service delivery and, ultimately, poor patient outcomes. Many organizations used this approach when diagnostic-related groups were first introduced, which threatened a largely unregulated charge structure. Leaders learned lessons from employing this methodology and when economic concerns became a reality again in the mid-1990s, they introduced an approach to reengineer the workforce component by cross-training personnel to achieve desired outcomes. Nurses were hardest hit by this approach because they were mandated to multitask clinical and nonclinical responsibilities. The result: care fragmentation yielding poor patient, nurse, and physician satisfaction.

The legacy report from the Institute of Medicine prompted community response. Through investigation, healthcare leaders found that most of the care provided to patients was grounded in tradition (information being passed from one generation to the next) rather than science. Care was often individualized by the practices of the practitioner rather than on the needs of the patient. A new paradigm needed to be created based on empirical evidence that translates to practice. Healthcare practitioners and leaders are searching for the answers to solve these debilitating problems...and it's believed that it can be found through evidence.

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What's evidence?

Well-executed science can produce evidence that a hypothesis is nothing more than a myth. Often we think we know the answers to questions, but in reality science proves something very different. As professionals, it's incumbent upon us to continue to search for appropriate evidence to ensure that the care provided is safe and efficient.

"Evidence is information. It supports or undermines a proposition, whether a hypothesis in science, a diagnosis in medicine, or a fact or point in question in a legal investigation."4 In healthcare, evidence can be best gathered using a systematic process that's best known as the scientific method, which attempts to determine a cause-and-effect relationship. The components of the scientific method include asking a question, conducting a literature review, developing a hypothesis, collecting and analyzing data, drawing a conclusion, and communicating results.5

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Types of evidence

Anecdotal, testimonial, and statistical are the most common types of evidence that healthcare practitioners employ. Anecdotal evidence is typically derived from the experience of one or more persons and isn't usually considered scientifically valid. Anecdotal evidence can provide insights into solving an issue and may often be the initial step into developing a research question. Practitioners should be careful to avoid the temptation to assimilate this evidence as fact because it commonly requires further analysis to transfer this information to practice.

Testimonial evidence is considered more reliable than anecdotal because it is information that's derived from an expert in a particular field of practice. Nurses will frequently seek advice and guidance from their more experienced colleagues and use this information when making clinical decisions. The difficulty in translating testimonial evidence into practice is that it may not be transferable to large groups of individuals or different clinical settings. Statistical evidence is considered the most substantial level of evidence because the foundation is built from a scientific and mathematical approach. Nurses and other healthcare practitioners must be astute when interpreting statistical data, as findings greatly hinge on the type of statistical analysis used and can infer an answer or a conclusion that isn't necessarily fact.

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6 levels of evidence

The lowest level of evidence can be obtained through expert opinion or consensus. Although these opinions are considered the lowest level, they're most readily used. Respected authorities in the area of clinical practice are likely seasoned practitioners who openly share their opinions with younger providers and influence the manner in which care is directed and delivered. Patients often rely upon experts in the field of medical practice and seek out multiple opinions from a variety of practitioners so that they can make informed decisions about their healthcare. Opinions add substantial value if they're based on medical science; however, many are based on folklore and arguable disagreement among providers, which could negatively affect a patient's clinical outcome.

An educational tool commonly used in healthcare is a case study. An in-depth analysis of a person's medical, social, psychological, and spiritual factors is completed to best understand a health status as it pertains to the individual's clinical presentation. This comprehensive inquiry provides clinicians the opportunity to become versed on a particular disease state and translate these findings to other clinical situations.

Nonexperimental research is typically done to describe, compare, or explore a particular area of interest. An important concept in this type of evidence gathering is that there's no manipulation of variables and no intervention on behalf of the investigator with the subject(s). This practice is commonly used to gain a better understanding on how independent variables might have an overall outcome. For instance, a researcher might want to gather factors that might be associated with morbid obesity. The investigator would examine obese patients and determine variables that might be associated with reasons that a person is overweight. Variables that the researcher would consider may include family history, patterns of eating, age, and sex. These variables would then be correlated to determine if these causes (independent variables) would have an effect (dependent variable) on an individual's weight.

Evidence gathering that's nonrandom is referred to as a quasi-experimental design. This type of evidence aggregation does have a control group and an experimental group; however, because it's not random it may not be easily translated into other populations. For instance, if an investigator is attempting to determine whether African American men are more likely to develop hypertension than other groups and only subjects from a particular geographic area are studied, the information gathered might not be applicable to translate this knowledge to the entire African American male population.

A randomized control trial is considered the best type of study because there's a completely randomized experimental group and a control group. This type of study is commonly used in the pharmaceutical industry to determine the effectiveness of medication therapy. The study follows the scientific method for inquiry and is easily transferrable to the general population.

A systematic review is the gathering of findings from all research studies conducted on a particular subject matter. After an intensive investigation, the researcher can analyze these results and render a comprehensive conclusion from the work completed by several researchers. The review of all the literature available on a subject matter has become the gold standard in the development and implementation of evidence-based care.

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Implications for nurse leaders

The implementation of evidence-based practice into the delivery of nursing care will be essential to combat the economic and environmental issues that are challenging healthcare. Nurse leaders will need to become fluent in gathering and interpreting evidence so that they can formulate an implementation plan to translate knowledge into practice.

Inclusive in the application of evidence-based practice is considering patient preference while applying a scientifically grounded plan of care. Paramount to the effectiveness of any intervention is to ensure that the clinician has attained the patient's agreement and participation in any action taken on his or her behalf. An infrastructure of nurse scientists and bedside practitioners with interests in determining new knowledge and innovation should be developed by the nurse leader to ensure that there's a constant influx of valid, reliable, and current information available to make cost-effective and efficient decisions in care delivery. Encouraging nurses to pursue educational opportunities will further enhance their ability to improve the care your patients receive.

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REFERENCES

1. Institute for Healthcare Improvement. Reducing VAP for long-term mechanical ventilation patients using the ventilator bundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/ReducingVAPLongTermMechanicalVentilationVentBundle.htm.

2. Dunn D, Koepke D, Pickens G, Center for Healthcare Improvement. The current recession and U.S. hospitals. http://thomsonreuters.com/content/PDF/healthcare/HospitalIndustryFinancialReport.

3. American Hospital Association. Trend watch chartbook 2007: trends affecting hospitals and health systems. http://www.aha.org/aha/trendwatch/chartbook/2007/07chapter4.ppt#10.

4. Miller DW, Miller CG. On evidence, medical and legal. J Am Phys Surg. 2005;10(3):70–75.


© 2010 by Lippincott Williams & Wilkins, Inc.

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