Developing an Evidence-Based Practice Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. Conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 2 Research utilization Evidence-based practice encompasses research utilization but also case reports and expert opinion Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 3 Multifaceted, systemic process of promoting adoption of evidence-based practices in delivery of health care services that goes beyond dissemination of evidence-based guideline Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 4 Dissemination: publications, conferences, consultations, and training programs Conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 5 Validates current practice, changes in practice, cost-effectiveness, and quality of care High-quality Cost-effective Outcomes Research Conduct Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. Research Utilization 6 Questions about current nursing practice Literature review Need for investigation Clinical research Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 7 Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 8 Develop and implement improved practice Other types of evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 9 Priority is given to projects in which a high proportion of practice is guided by research evidence. If a practice change is warranted, changes are implemented using a process of planned change. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 10 EBP is refined based on evaluation data. Outcomes are monitored. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 11 Selecting a topic Problem-focused triggers ➢ Quality improvement data ➢ Risk-surveillance data ➢ Benchmarking data ➢ Financial data ➢ Recurrent clinical problems Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 12 Selecting a topic Knowledge-focused triggers ➢ Reading research ➢ Listening to scientific papers at research conferences ➢ Reviewing EBP guidelines published by federal agencies or specialty organizations Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 13 Critical that staff members: ➢ Be involved in selecting the topic ➢ View the potential practice as contributing significantly to patient care Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 14 Forming a team ➢ Composition of the team ➢ Key stakeholders identified Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 15 Identification of key stakeholders: ➢ How are decisions made? ➢ What types of changes will be needed? ➢ Who is involved in decision-making? ➢ Who is likely to lead and champion implementation? ➢ Who can influence the decisions? ➢ What type of cooperation is needed? Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 16 Question clearly defined: ➢ Types of people and patients ➢ Interventions or exposures ➢ Outcomes ➢ Relevant study designs Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 17 Consider using PICO ➢ Patient, population, or problem ➢ Intervention or treatment ➢ Comparison intervention or treatment ➢ Outcomes Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 18 Evidence examined should include: ➢ Clinical studies, meta-analyses, integrative literature reviews, and existing EBP guidelines Identify key search terms Use the expertise of health science librarians 19 Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. It is helpful to categorize articles and read in this order: ➢ Clinical (nonresearch) ➢ Theory articles ➢ Integrative and systematic reviews ➢ Synthesis reports ➢ EBP guidelines ➢ Research articles ➢ Meta-analyses Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 20 There are many grading schemas available but all address: ➢ Quality of the individual research ➢ Strength of the body of evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 21 Before reviewing the literature, it is imperative that the team agree on: ➢ Methods for categorizing the type of research ➢ Rating the quality of individual articles ➢ Grading the strength of the body of evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 22 Date of publication or release Authors of the guideline Endorsement of the guideline Clear purpose of what the guideline covers and the patient groups for which it was designed Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 23 Types of evidence (research, nonresearch) used in formulating the guideline Types of research included in formulating the guideline Description of the methods used in grading the evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 24 Search terms and retrieval methods used to acquire research and nonresearch evidence used in the guideline Well-referenced statements regarding practice Comprehensive reference list Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 25 Review of the guideline by experts Whether the guideline has been used or tested in practice and, if so, with what types of patients and in what types of settings Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 26 Best as a group project ➢ Journal club ➢ Novice and expert ➢ Assistance from students ➢ Use graduate students ➢ Class project Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 27 Use summary tables to synthesize information and include: ➢ Study purpose ➢ Research questions and hypotheses ➢ Variables studied ➢ Description of sample and setting ➢ Research design ➢ Methods used to measure each variable ➢ Description of the intervention tested ➢ Findings Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 28 Practice changes based on evidence Consider: ➢ Relevance ➢ Consistency ➢ Sample characteristics ➢ Feasibility ➢ Risk-benefit ratio Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 29 Put in writing the evidence base of the practice. Clinicians need to know: ➢ That recommended practices are based on evidence ➢ The type of evidence (e.g., randomized clinical trial, expert opinion) used in developing the EBP standard Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 30 Implementing the practice change ➢ Rogers’ model on diffusion of innovations ▪ Nature of the innovation ▪ Manner in which it is communicated Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 31 Characteristics of innovations that influence adoption: ➢ Advantage ➢ Compatibility ➢ Complexity Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 32 Strategies to promote adoption: ➢ Reinvention of the EBP guideline to fit the local context ➢ Use of quick reference guides and decision aids ➢ Use of clinical reminders Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 33 Methods of communicating change: ➢ Mass media ➢ Educational strategies ➢ Opinion leaders ➢ Change champions ➢ Core groups ➢ Educational outreach ➢ Performance gap assessment ➢ Audit and feedback Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 34 Social context and change ➢ Strong leadership ➢ Clear strategic vision ➢ Good managerial relations ➢ Visionary staff in key positions ➢ A climate conducive to experimentation and risk taking ➢ Effective data capture systems ➢ Available resources to support change Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 35 Goal is to collect and analyze data with regard to use of a new EBP and then to modify the practice as necessary. Evaluation should include both: ➢ Process measures ➢ Outcome evaluation Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 36 Findings must be provided to clinicians to: ➢ Reinforce the impact of the change in practice ➢ Ensure that they are incorporated into quality improvement programs Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 37 Education must include knowledge and skills in the use of research evidence in practice. Communicate and integrate EBP into nursing profession. Professional responsibility of all nurses to read and use research in their practice and to communicate with nurse scientists the many and varied clinical problems for which we do not yet have a scientific base. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 38 A. The researcher B. A direct care provider C. The hospital administrator or CEO D. The head nurse or CNO E. A mixture of management and direct care providers Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 39 A. Education specialist B. Information technologist C. Opinion leader D. Risk manager Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 40 A. Strong leadership B. Clear strategic vision C. Visionary staff in key positions D. A climate conducive to experimentation and risk taking E. All of the above Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 41 A. Patient outcomes B. Cost savings C. Who is successfully using it D. Barriers overcome Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 42 CHAPTER 19 Strategies and Tools for Developing an EvidenceBased Practice Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 2 TOOL #1: ASKING A FOCUSED CLINICAL QUESTION Develop the question by addressing these four issues: 1. 2. 3. 4. Population Intervention Comparison Outcome Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 3 CATEGORIZE THE CLINICAL QUESTION 1. Therapy category: ➢ Experimental or quasi-experimental ➢ Outcome known ➢ Therapy appraisal tool at: http://www.casp-uk.net/wpcontent/uploads/2011/11/CASP_RCT_Appraisal_Checklist_1 4oct10.pdf. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 4 CATEGORIZE THE CLINICAL QUESTION 2. Diagnosis category: ➢ Cross-sectional ➢ Comparison of the new and the “gold standard” ➢ Diagnostic tool at: http://www.casp-uk.net/wpcontent/uploads/2011/11/CASP_Diagnostic_Appraisal_Che cklist_14oct10.pdf. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 5 CATEGORIZE THE CLINICAL QUESTION 3. Prognosis category: ➢ Nonexperimental ➢ Follow-up ➢ Determination of factors ➢ Prognosis tool at: http://www.casp-uk.net/wpcontent/uploads/2011/11/CASP_Cohort_Appraisal_Checkli st_14oct10.pdf Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 6 CATEGORIZE THE CLINICAL QUESTION 4. Harm category: ➢ Nonexperimental ➢ Exposure ➢ Harm appraisal tool at: http://www.casp-uk.net/wpcontent/uploads/2011/11/CASP_CaseControl_Appraisal_Checklist_14oct10.pdf. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 7 TOOL #2: SEARCHING THE LITERATURE Consult librarian Tutorial for PubMed at www.nlm.nih.gov/bsd/disted/pubmed.html#qt Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 8 TOOL #3: SCREENING YOUR FINDINGS Peer-reviewed journal? Similar setting and sample? Study sponsorship? Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. TOOL #4: APPRAISE EACH ARTICLE’S FINDINGS Therapy studies ➢ Is there a difference between two or more treatments? ➢ Numerical values are either continuous or discrete. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 9 10 CONTINUOUS AND DISCRETE VARIABLES Objective Variable Outcome CONTINUOUS VARIABLES Change after exposure to intervention Pain score Levels of distress Blood pressure Weight Measures of central tendency DISCRETE VARIABLES “Event” occurred or did not occur Death Diarrhea Pressure ulcer Pregnancy Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. Measures of event probability 11 DIAGNOSIS ARTICLES Sensitivity is the proportion of those with disease who test positive; that is, sensitivity is a measure of how well the test detects disease when it is really there—a highly sensitive test has few false negatives. Specificity is the proportion of those without disease who test negative. It measures how well the test rules out disease when it is really absent; a specific test has few false positives. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 12 SENSITIVITY Measure of Accuracy Sensitivity Definition Comments Ability of the test to detect the proportion of people with the disease or disorder of interest TP/(TP + FN), where TP and FN are number of true-positive and falsenegative results, respectively Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 13 SPECIFICITY Measure of Accuracy Specificity Definition Comments Ability of the test to detect the proportion of people without the disease or disorder TN/(TN + FP), where TN and FP are number of true-negative and falsepositive results, respectively Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 14 PROGNOSIS ARTICLES Odds ratio: Probability of developing the outcome or a particular disease. Indicates how much more likely certain independent variables (factors) predict the probability of developing the dependent variable (outcome or disease). Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 15 ODDS RATIO Odds ratio ➢ The odds ratio (OR) best describes the data in casecontrol studies. ➢ The OR = probability of an event ➢ Calculated by dividing the odds in the treated or exposed group by the odds in the control group Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 16 HARM ARTICLES Used to determine if an individual has been harmed by being exposed to a particular event Case-control design: investigators select the outcome they are interested in (e.g., pressure ulcers), and examine if any one factor explains those who have and do not have the outcome of interest. The measure of association that best describes the analyzed data in case-control studies is the odds ratio. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 17 META-ANALYSIS A research method that statistically combines the results of multiple studies (usually randomized clinical trials) to answer a focused clinical question through an objective appraisal of carefully synthesized research evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 18 META-ANALYSIS Terms “meta-analysis,” “systematic review,” and “integrative review” are used interchangeably. Meta-analysis is a quantitative approach to a systematic review, whereas an integrative review uses a nonquantitative approach. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 19 META-ANALYSIS Meta-analyses and integrative reviews are both considered systematic reviews and provide level I evidence. Each uses a standardized process, which has a set of preestablished criteria that guide its implementation. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 20 STEPS IN A METAANALYSIS Clinical question Search for all relevant studies What studies are included Assess the quality of each study Studies statistically combined Conclusion Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 21 MEASURES IN METAANALYSIS SYSTEMATIC REVIEW The OR is the statistic of choice for use in a metaanalysis. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 22 INTERPRETING ODDS RATIOS Odds ratio Type of Outcome Adverse outcome Beneficial outcome Less than 1 Intervention better Intervention worse = to 1 (null) Intervention no better or worse Intervention no better or worse Greater than 1 Intervention worse Intervention better Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. WHAT IS THE MOST IMPORTANT STEP IN APPLYING EVIDENCE TO PRACTICE? 23 A. PICO (population, intervention, comparison, and outcome) B. Critically reviewing the literature C. Putting the research into practice D. Evaluating efficacy of the new practice Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. WHICH EBP CLINICAL CATEGORY WOULD THE NURSE BE USING IN THE FOLLOWING SCENARIO? 24 A clinical nurse has noticed an increased incidence in urinary tract infections and would like to find the best practice to minimize this. A. Therapy B. Diagnosis C. Prognosis D. Harm Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. WHEN COMPLETING A LITERATURE SEARCH FOR A CLINICAL QUESTION, WHAT IS THE FIRST RESOURCE THE NURSE SHOULD USE? 25 A. Evidence-based nursing B. CINAHL C. PUBMED D. Cochrane review Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. FOR THE NURSE WHO HAS LIMITED TIME TO REVIEW A RESEARCH ARTICLE, WHERE WOULD BE THE BEST PLACE TO FIND THE ANSWER TO THE Abstract CLINICAL QUESTION? 26 A. B. Method C. Conclusion D. Table Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. THE NIGHTINGALE LEGACY CHILD HEALTH 2000 International Pediatric Nursing Conference Friday, June 2, 1995 Heather F. Clarke, RN, PhD Nursing Research Consultant Registered Nurses Association of British Columbia, Vancouver, B.C., Canada 1 INTRODUCTION "The time has come the walrus said to talk of many things, of sailing ships and sealing wax and cabbages and kings". Indeed the time has come - and its a time of reform - not just a tinkering around the edges - but of rule breaking; not just reducing/maintaining costs but of reengineering - doing more with less; not just developing new technologies but of their creative use. Albert Einstein's wisdom is as relevant today as it was decades ago "The significant problems we face cannot be solved at the same level of thinking we were at when we created them." The clues that it is a time for calling in the chits include: - evidence-based practice is "in" - ritual and intuition are "out" - inappropriate/ineffective diagnostic and therapeutic interventions are not being tolerated - evidence-based tools for decision-making in practice (e.g. CPGs, Care Maps, Critical Paths) are proliferating and being made widely accessible (e.g. on-line, internet) accountability for outcomes is demanded of each and every health care profession - the "lone ranger" practitioner is neither effective nor tolerated - "collaborative" practice is taking on many shapes and sizes - consumer participation in decision making is not an option - the medical model (paradigm) has been replaced (by many if not most) by the consumer model (paradigm) In this era of shared responsibility and cost-consciousness, patient preferences are a key element of health care decisions and should be considered in the development of practice guidelines. How come it is taking us so long to recognize these clues - to re-conceptualize our world of professional nursing - to clearly demonstrate how nursing care makes a difference - how health care resources and therapeutic nursing interventions are effectively and efficiently utilized 2 to improve the health status of clients of our health care system? Clearly, there is a need to improve the research and evidence bases of our practice. This is the Nightingale Legacy Research and Practice. In Nightingale's view, nursing should be a search for truth. She held that the ability to collect accurate information and make correct observations is essential. "If you cannot get the habit of observation one way or other, you had better give up being a nurse, for it is not your calling, however kind and anxious you might be"(1) However, promoting and implementing research-based practice is not a simple task; nor is it solely reliant upon nurses in clinical practice. There are forces affecting the advancement of research-based practice within both the health care and nursing systems. I know Dr. Ritchie is going to address this as well, so I am going to focus more on some "how come" questions related to research-based nursing practice and discuss two interrelated processes which must be attended to if the "how come" questions are to be turned into "why not" questions - or "just do it" approaches. And I am going to address this with particular emphasis on research utilization. HOW COME? How come there is a gap between knowledge generation and application? Is it that research is not seen to be relevant to practice? If so, how come we aren't getting the relevant research done? Are we not asking the right or relevant questions? We know nurs es have questions - consider those generated through the provincial Agency Challenge and agency dinosaur and sacred cow challenges. There are relevant questions. So - How come they are not being explored? Are researchers not listening to those questions? And even if they are to some 3 extent - How come clinicians are not more engaged in answering those questions? Furthermore sometimes there are answers to the practice relevant questions. How come we're not using the research? Example: Internet - IM Injection Sites In the clinical arena the challenges of promoting research-based practice require a different view of our world - they require us to create a new future. How we shape our future will depend to great extent on how we perceive the clues I mentioned earlier - do we see them as threats? or opportunities? do we see this as a loss? or a gain? I believe it is time to turn our nursing system upside down: From one that is currently unstable  poorly balanced  difficult for responsive decision-making  inappropriate for knowledge diffusion and distillation (promotes evaporation instead)  not strategically situated to meet today's challenges to one that is  firmly grounded on evidence and research-based knowledge  stable  encourages diffusion and distillation of knowledge 4  maximizes the potential of each resource (clinicians, educators, administrators and researchers) Let's go back to one of the "how come" questions. How come we're not using the research-based knowledge that we have in our practice?  are we unaware of the difference it would make - or do we either not believe the research findings - or not believe that we have "permission" to use them?  Nurses tend to be perfectionists, looking for absolute proof of all facts before a piece of research is deemed usable(2)  do we not value this aspect of our responsibilities?  do we lack the infrastructure and/or competencies to support such activity?  is there a lack of incentive to do so?  are we unaware of frameworks available to assist us in the process? In this section of the presentation I will focus on two processes - diffusion and adoption of innovations and use of research utilization models/frameworks - processes that have the potential to facilitate the use of research in nursing. I will tell you a couple of success stories to illustrate my point. We know that neither the mere existence or dissemination of knowledge nor enforced behavior change ensure that attitudes, values and behaviors will change (3). Using research findings in nursing practice can be thought of as adoption of an innovation - a complex process which involves several stages. 5 Rogers'(4) (1983) theory of diffusion of innovations with its four successive stages is a good place to start. The first stage - knowledge - occurs as nurses become aware of the innovation. Next, in the persuasion stage, they form a favorable or unfavorable attitude toward the innovation. Thirdly, nurses make decisions to adopt or reject the innovation, at least on a trial basis. If a new practice is mandated without practitioners moving through these appropriate stages, it is unlikely that the innovation w ill be implemented consistently or as intended. Consistent application with evaluation occurs in the fourth confirmation stage - if progress has been successful through the previous stages. A number of researchers have found that the source for new knowledge influences the rate at which individuals pass through the first stage. Print-media and interpersonal contacts (research-oriented conferences and inservice programs and role models) are most influential in solving clinical problems and adopting innovations (Brett(5), Coyle and Sokop(6), Means(7), Salasin and Cedar(8), Stinson and Mueller(9)). Although educational programs are suggested as important methods of research dissemination, few studies have examined the extent to which research findings are incorporated into nursing curricula. In 1995, Barta(10) reported on a study that investigated pediatric nurse educators' inclusion of evidence-based pain management techniques in the curriculum. Practices most highly diffused among pediatric nurse educators were use of pain scales, providing sensory information and teaching self-comforting strategies. However, only the use of pain scales was in the "include always" range. The least diffused innovation in this sample was the use of TENS (transcutaneous electrical nerve stimulation). It's interesting to note that at the 1992 International Pediatric Nursing Conference at Child Health 2000, Dr. Leora Kutner11 spoke about desirability 6 (in fact predicted) that physical methods to ease pain would become more commonplace including therapeutic touch, massage and TENS - and that this would reflect the growing appreciation of the research that shows that pain can be shifted by means other than pharmacological. However, sadly in a 1994 report from Alberta, Williams'12 study of nurse educators in that province we learn that there is a significant lack of fundamental know-how about the pharmacological management of acute pain - that little time is spent on pain management in nursing curricula and that content is often spontaneous rather than planned. In Barta's study the educators chose nursing journals, nursing texts and Cumulated Index of Nursing Literature, as most useful sources of information for updating instruction of baccalaureate degree students. One has to seriously question the currency of texts and their appropriateness as a source of update! Factors influencing nurses in the persuasion stage are agency policy, procedure manuals, and the opinions of other professionals. Rather than actual agency policy about research-based nursing practice, Brett(13) found that it was perceived policy that influenced innovation adoption behavior among her sample of hospital nurses. In the last two innovation adoption stages, the most common barriers identified by clinicians were organizational barriers. Nurses' perception that they lack authority and support of administration to change nursing practice inhibits innovation adoption. Romano's (14) identified five attributes of the innovation, as perceived by potential users that affect the rate of its adoption. Innovations which have an obvious advantage to the patient/client; are compatible with nurses' values and experiences; are relatively simple to understand and implement; can be tested and evaluated; and demonstrate results are likely to be 7 adopted relatively quickly - with nurses passing through each of the four stages quickly and without much angst. However, problems are sure to arise when at least one of these attributes differ and when attention is not paid to assisting nurses move through the four stages in a logical and timely fashion. PCA Example In 1991 members of the RNABC Nursing Research Committee Network questioned why their staff nurses were not using the Patient Controlled Analgesia approach, including the pump, as intended and supported by research. Subsequently an 11 site research study w as carried out by 13 nurse-investigators. The purpose of the study was to determine nurses' learning needs to bring about effective and efficient implementation of a PCA approach within the complexity of decision-making about pain management. We used Rogers'(15) innovation adoption framework, paying special attention to two of the five attributes of PCA (the innovation) not previously investigated - compatibility of PCA with nurses' existing values and experiences and complexity of the approach. We found that nurses' beliefs related to PCA changed in varying degrees depending upon the accumulation of positive or negative forces in their agencies. Positive forces included planned implementation, education/clinical experience and positive outcomes for most patients, even the chemically dependent. Nurse-involvement in patient selection for PCA was another positive force, as was the ease of pump use and safety features. The timing of learning and clinical application of new information and skills was as important as the availability of knowledgeable peer supported clinical experience. The positive forces enhanced nurses' ability to 8 adopt a new perception of the PCA approach and supported them in the transformation of their pain management beliefs. Negative forces were opposite of the positive forces and included increased workload during early phases of PCA implementation. These negative forces inhibited the implementation of PCA and changes in pain management beliefs. Our findings support the need to systematically address five issues when embarking on the innovation adoption process: 1. availability of research-based knowledge - Is it available in clinically focused journals, conferences, or electronic communication systems? 2. acceptability and readability of that knowledge - is it worded in jargon that only a researcher can understand? 3. credibility of the study - do nurses believe the findings, given their understanding of the research methods? 4. relevancy of the findings - how relevant are the findings to clinical practice, the sociocultural context of practice and clients, and organizational structures? 5. support and reinforcement to adopt and maintain the innovation - are there supportive persons and materials to assist nurses to adopt and practice innovations? WHY NOT? Why not change this how come into a "just do it"? What resources/processes are there to assist moving through the innovation adoption process? One is a research utilization framework. 9 A research utilization framework can facilitate the research adoption process and the resolution of some of the above mentioned issues. The four best-known frameworks are the Western Interstate Commission for Higher Education in Nursing, also called WICHEN(16); the Conduct and Utilization of Research in Nursing or CURN(17), NCAST(18) and Stetler/Marram(19). WICHEN and CURN frameworks are both based on the concepts of diffusion of innovation and planned change; NCAST focusses solely on diffusion of innovations; and the refined Stetler/Marram framework is an interactive, staged model. Based on the work of Stetler (20) and the expressed needs of nurses and health care agencies in British Columbia, a decision-making model for utilization of research findings in practice was developed and published in the workbook Nursing Research: From Question to Funding(21). Application of this framework requires partnerships among nurses with clinical expertise, research experience, and administrative responsibilities. Each of the four phases requires particular nurses to be involved, decisions to be made, and resources to be accessed. The framework can be modified by individual agencies, thus making it relevant to both staff needs and the organizational structure.
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