Evidence-based practice, quality improvement, and research: A visual model : Nursing2023

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Evidence-based practice, quality improvement, and research

A visual model

Grys, Crystal A. MSN, RN

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Nursing 52(11):p 47-49, November 2022. | DOI: 10.1097/01.NURSE.0000889812.89287.45
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Many organizations have achieved success with the American Nurses Credentialing Center's Magnet Recognition Program®, and others are on the journey toward this goal. Inherent in the Magnet Recognition Program is the adoption of practice that is based on the best-possible evidence and a culture of inquiry that adopts a continuous quality improvement mindset.1,2 The integration of quality improvement (QI), evidence-based practice (EBP), and research into the healthcare setting can improve patient outcomes, increase quality, and reduce the cost of care.3 In a broader context, these can also apply to the operational and logistical aspects of practice. Discerning the differences between QI, EBP, and research can be difficult because of their many overlapping features.4 This article aims to help nurses who are unfamiliar with these concepts to be able to compare and contrast the three concepts and put them into context by way of two visual models.

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Figure:
Visual model of similarities and differences between QI, EBP, and research

EBP, QI, and research in nursing education and practice

Nurses with a PhD in nursing, a research-focused degree, ask questions and design studies that generate new knowledge. Nurses with a DNP, a clinical practice degree, translate new evidence into practice.5 They are also skilled in QI projects since DNP programs require QI projects as part of the curriculum. Approaches to QI projects may include methods like Plan-Do-Study-Act, or tools that are part of Six Sigma or Lean paradigms.6,7 Six Sigma is a process improvement approach that is intended to reduce errors and often employs investigational or analytic tools.8 Lean is a method to increase the efficiency and quality of a process by reducing different types of “waste.”7 These approaches are sometimes used together because their methods are related and complementary.8 Nurses with a Bachelor's degree are educated in EBP, which often uses PICOT (Population, Intervention, Comparison, Outcomes, and Time) to formulate a targeted query of the literature. While PICOT can be a tool to frame a literature search for a QI project or to inform a research project, it is a primary tool for EBP in the translation of evidence into practice.

Key similarities and differences

Understanding the key similarities and differences between QI, EBP, and research is important to determine the best approach to solve problems. Furthermore, certain problems require particular skill sets, so the alignment of roles and methods is vital for success (see Visual model of similarities and differences between QI, EBP, and research). QI and EBP are similar in that they are both used during practice.4 EBP is used to care for individual patients, address operational and systemic questions, or improve safety or quality outcomes.7 QI projects are used to fix or build a new process specific to the local practice and informed by local data and evidence from the literature.4,7 Research studies are similar to EBP in that they are both primarily grounded in evidence from the literature.4 Where they differ is that research is used to generate new evidence using the scientific method, which involves testing a hypothesis, observing and analyzing results, and using the results to establish a knowledge base, while EBP initiatives translate existing evidence on patient care or optimization of operations.7,9 Research studies are similar to QI projects in that both ask questions to solve problems.4 Research studies produce results that are generally applicable to many other similar settings, while the results of a QI project are often limited or specific to a particular practice or population.7,10

While QI, EBP, and research have been well defined, a conceptual model showing their interplay could help display attributes and relationships in a way that may engage a wider audience of learners (see Visual model of the functional relationship between QI, EBP, and research).4,7 Questions inspired by a curious practice can spur research studies that generate new knowledge and feedback into the practice as new evidence. When there are problems or issues related to quality or efficiency in the practice, QI activities can yield process improvements. Reviewing examples of QI, EBP, and research can better illustrate the differences and similarities (see Examples of QI, EBP, and research).

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Figure:
Visual model of the functional relationship between QI, EBP, and research

Integrating QI, EBP, and research throughout the organization is important to optimize clinical outcomes. These activities are often ongoing across an organization and facilitated by team members who serve in different roles. As such, it is useful to clearly define the roles and processes to ensure that they are resourced appropriately. By understanding the interplay of QI, EBP, and research, nurses may find it easier to begin contributing to these activities. Engaged nurses may find it rewarding to align their efforts with QI, EBP, or research knowing that their efforts will support the Quintuple Aims of Healthcare, including population health, patient experience, quality outcomes, caring for healthcare providers, and health equity.11-13

Examples of QI, EBP, and research

QI

  • Standardizing skin inspection and risk assessment to reduce pressure injuries
  • Optimizing the use of sepsis bundles
  • Implementing a process to remove indwelling urinary catheters within a certain time frame
  • Examining ways to reduce medication administration errors
  • Reviewing specimen labeling practices to reduce errors
  • Employing a gap analysis to determine how to better prepare nurse preceptors

EBP

  • A clinical nurse educator implementing a patient positioning program to reduce the risk for pressure injuries
  • A nursing informaticist using evidence to inform the design of a decision support tool for a new visit type
  • A nurse leader using evidence to implement a new staffing model to improve a unit's operational efficiency
  • A nurse leader implementing a resource prioritization system for annual planning and budgetary/financial management

Research

  • A randomized controlled trial studying new wound care approaches, such as a new pressure-relieving support surface
  • A randomized controlled trial evaluating the efficacy of a nurse visit after discharge for patients with a myocardial infarction

REFERENCES

1. American Nurses Credentialing Center. 2019 Magnet Application Manual. American Nurses Credentialing Center; 2019.
2. Carter EJ, Mastro K, Vose C, et al. Clarifying the conundrum: evidence-based practice, quality improvement, or research?: The clinical scholarship continuum. J Nurs Adm. 2017;47(5):266–270. doi:10.1097/NNA.0000000000000477.
3. Melnyk BM, Morrison-Beedy D. Generating evidence through intervention research versus using evidence in evidence-based practice/quality improvement. In: Melnyk BM, Morrison-Beedy D, eds. Intervention Research and Evidence-Based Quality Improvement. 2nd ed. Springer Publishing Company; 2018. doi:10.1891/9780826155719.0001.
4. Shirey MR, Hauck SL, Embree JL, et al. Showcasing differences between quality improvement, evidence-based practice, and research. J Contin Educ Nurs. 2011;42(2):57–68; quiz 69-70. doi:10.3928/00220124-20100701-01.
5. Gaines K. DNP vs Ph.D. in nursing - what is the difference? https://nurse.org/education/dnp-or-phd-in-nursing-difference/.
6. Donovan EA, Manta CJ, Goldsack JC, Collins ML. Using a Lean Six Sigma approach to yield sustained pressure ulcer prevention for complex critical care patients. J Nurs Adm. 2016;46(1):43–48. doi:10.1097/NNA.0000000000000291.
7. Polit DF, Beck CT, eds. Quality improvement and improvement science. In: Nursing Research: Generating and Assessing Evidence for Nursing Practice. 11th ed. Wolters Kluwer; 2021.
8. Lee JY, McFadden KL, Gowen CR 3rd. An exploratory analysis for Lean and Six Sigma implementation in hospitals: together is better. Health Care Manage Rev. 2018;43(3):182–192. doi:10.1097/HMR.0000000000000140.
9. Winstead-Fry P. The scientific method and its impact on holistic health. Adv Nurs Sci. 1980;2(4):1–8.
10. The Federal Register. Code of Federal Regulations Title 45, Subtitle A, 46.102. 2022. www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46/subpart-A/section-46.102.
11. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–769. doi:10.1377/hlthaff.27.3.759.
12. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–576. doi:10.1370/afm.1713.
13. Nundy S, Cooper LA, Mate KS. The quintuple aim for health care improvement: a new imperative to advance health equity. JAMA. 2022;327(6):521–522. doi:10.1001/jama.2021.25181.
Keywords:

evidence-based practice; nursing; quality improvement; research; visual models

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