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Pulling it all together

QI, EBP, and research

Hedges, Christine RN, ACNS-BC, CCNS, PhD

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doi: 10.1097/01.NURSE.0000360442.96709.3e
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Unless you've been removed from civilized society for the last decade, it's likely that you've been exposed to the movement in healthcare known as evidence-based practice (EBP). Medical and healthcare professionals are recognizing the importance of providing care that's based on sound, scientific research evidence and rejecting, or at least questioning, practice according to status quo, ritual, routine, or reliance on the sacred cows of the past. The evidence movement hasn't escaped the notice of patients and journalists either. The word evidence repeatedly pops up in the lexicon of healthcare consumers who search the Internet, watch television, or read scientific literature in the print press with greater ease and access to medical information than at any time in the past.

Consistent with acquiring any new information or technology, healthcare providers have the responsibility to become knowledgeable and competent in EBP in order to keep current and be able to provide their patients and clients with the most up-to-date care. However, the challenge of learning and practicing EBP requires a specific skill set and access to expertise not formally required of nurses in the past. A brief in-service or one-size-fits-all workshop is unlikely to provide the expertise needed to sustain an EBP momentum; rather, such momentum requires a major paradigm shift within an organization, acknowledging the importance of reading and understanding research articles, finding appropriate care guidelines, understanding statistical results, synthesizing evidence, and translating best evidence into practice.

Although many barriers to practicing EBP have been identified by nurses, a common question posed by many nurses is: How are quality improvement (QI), EBP, and research different and who's responsible for each?1 Often, the paradigm is to view these three entities as working together, all supporting an overarching EBP.2 The distinction among QI, EBP, and research continues to hold some confusion among nurses.

Definitions review

Quality has been defined as “the degree of excellence possessed by a product, service process, or workforce.”3 It's a term frequently employed in the business setting and has occupied a position of importance in the delivery of healthcare for many decades. Historically, QI can be traced back to the work of William Deming, who's credited with improving production in the automotive industry, initially in Japan, through the monitoring and testing of the quality of products. In the 1980s and 1990s, the quality movement was often referred to in other terms, such as performance improvement and continuous QI, which encompass the cyclic and often repeated measures performed by an organization to achieve targeted outcomes and goals. In healthcare settings, nurses use QI methods in frequent cycles to continually evaluate their workflow and processes until desired patient and patient-related outcomes are achieved.

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EBP has been defined as “the integration of best research evidence with clinical expertise and patient values.”4 The birth of EBP in medicine is often credited to Dr. Archie Cochrane, a Scottish epidemiologist, who believed that scientific evidence, particularly the results of randomized controlled trials, should guide clinical decision making. EBP has been further described in nursing literature as “a problem-solving approach to clinical practice that integrates a systematic search for, and critical appraisal of, the most relevant evidence to answer a burning clinical question, one's own clinical expertise, and patient preferences and values.”5 Models of EBP vary in structure and complexity, but all start with a clinical question, often in PICO (population, intervention, comparison, outcome) format. This query is followed by a complete review of the available literature, evaluation of the evidence, synthesis of the findings, and a decision-making process by all stakeholders to evaluate the evidence before translation into practice.

Nursing research can be defined as a “systematic inquiry that uses disciplined methods to answer questions or solve problems.”6 A key feature of research, therefore, lies in the generation of new knowledge through rigorous processes of inquiry. Research can involve an array of methods and designs ranging from qualitative interviews to intervention studies, but all techniques have the common factor of adhering to scientific methodology, with the intent of producing and disseminating new knowledge in the resultant study findings. In the hospital setting, research is usually conducted by research teams, often led by nurse scientists or other scholars who possess expertise in research methods.

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Despite these clear-cut definitions, practitioners may still feel confused because QI involves systematic processes of data collection and inquiry. Moreover, is it possible that, in performing QI or EBP, new knowledge may emerge for the practitioner? EBP integrates evidence from research studies employing rigorous methodology, causing one to ponder whether he or she needs to be a research producer or a research consumer. Herein lies the slippery slope, one that not only has problems of nomenclature, but also ethical concerns, such as the necessity to obtain institutional review board (IRB) oversight for hospital- and unit-based projects and the use of protected health information when exploring data.

Interconnections

This brings us to the question: Who's responsible for QI, EBP, and research? Many models of EBP exist and organizations may have adopted a particular model or may have chosen to integrate elements of several models to create the best fit in their environment. Models commonly seen in nursing are the Iowa Model of Evidence-Based Practice, the Advancing Research and Clinical Practice through Close Collaboration Model, and the Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation, to name a few. But as long as the model integrates the basic EBP principles of evaluating evidence from research, clinical expertise, and patient preference, it will support the belief that nurses at all levels of practice are responsible for EBP. Moreover, it's now a widely held belief that all nurses, whatever their educational preparation, are responsible for research consumption and participation.7

Nurse managers occupy a unique position in ensuring that EBP is supported and should be the leaders who pull it all together for their staff. They're often the first to be asked the burning clinical questions and can direct nurses to appropriate resources, such as nurse researchers, advanced practice nurses, nursing research councils, EBP councils, and medical center librarians. Nurse managers can ensure that staff nurses are familiar with their unit's QI measures and nursing quality indicators and, depending on the nurse's clinical career ladder trajectory, can encourage participation in data collection and monitoring on a unit level. Moreover, nurse managers and administrators who initiate or facilitate EBP projects provide the link to a wider array of institutional and regulatory agency goals and benchmarks. A nurse's career advancement and development in research can be greatly facilitated by nurse managers who serve as mentors or find appropriate mentors for nurses interested in research. And, finally, managers can help nurses navigate the slippery slope of QI, EBP, and research definitions by ensuring that all potential projects are reviewed by the appropriate councils and IRBs so there are no breaches of federal regulation codes of research, ethics, or patient confidentiality.

Best evidence, better practice

QI, EBP, and research, although seemingly distinct in definition, are all integral parts of the translation of best evidence into practice in order to provide optimal patient care. And nurses are uniquely positioned to facilitate the journey.

References

1. Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice. Am J Nurs. 2005;105(9):40–51.
2. Hedges C. Research, evidence-based practice, and quality improvement. AACN Adv Crit Care. 2006;17(4):457–459.
3. Wojner AW. Outcomes Management. St. Louis, MO: Mosby; 2001.
4. Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. London, U.K.: Churchill Livingstone; 2000.
5. Melnyk BA, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
6. Polit DF, Beck CT. Essentials of Nursing Research: Methods, Appraisal, and Utilization. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
7. LoBiondo-Wood G, Haber J. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. St. Louis, MO: Mosby Elsevier; 2006.
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