Implementing Research in the Clinical Setting


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Joanne Schottinger, MD

Increasing competence in information literacy is the foundation for EBP; this provides nurses with the skills to be literate consumers of information in an electronic environment Emanuel et al. According to Emmanuel et al.

Advanced Topics for Implementation Science Research: Use of theory in implementation research PARIHS

The use of sophisticated equipment and electronic assessment care packages requires nurses to be competent in IT skills. For students to be ready for EBP learning, they need to have good basic computer skills and to develop the right attitude towards learning using EBP. Their learning styles must support the inculcation of EBP.

Students should have the right attitude for functioning as independent health care providers Young et al. Nursing education institutions NEIs have a responsibility to provide support to student nurses in the development of relevant IT skills. This calls for services of the librarian to provide skills to student nurses in searching electronic databases for evidence.

Clinical librarians in health services have to promote information literacy in the workplace. The recommendations that were made by the participants concerning student nurses were about creating good networking between the clinical practitioners and nurse educators to support the student nurses, providing students with basic computer skills so that they can work independently, and introducing a reward system as motivation for student nurses who are doing well.

It showed ways in which EBP teaching and learning could benefit the nurse educator, the nursing education discipline, student nurses, patients, and the employer or institution. The following categories of information offer the benefits that come with implementation of EBP in teaching and learning.

Participants believed that EBP empowers and enriches the nurse educators and student nurses with up-to-date information, thus keeping their knowledge current. They also believe that EBP is based on researched international studies, and grounded on expert knowledge. These remarks were made by participants:. Nurse educators displayed a positive attitude and appeared to be very supportive of EBP teaching and learning. Reinforcing this statement, Mehrdad et al. Therefore, nurse educators and nursing students need to keep up to date with current evidence for use in practice.

Current practices relied on by senior nurses and nurse educators are frequently based on personal experience, tradition, intuition, and organisational policies or protocols, rather than on evidence Malik et al. There is a belief that the use of up-to-date scientific findings will improve the quality of care for patients and fill the gap between research, theory, and practice Mehrdad et al. It is important that nurses use evidence to ensure their practice is up to date and based upon the best available research Hickman et al.

Malik et al. According to the nurse educators, student nurses lack interest in research. However, once they become involved with research activities, the tendency is for students gradually to develop more interest and a concomitantly positive attitude towards research. Equally, increased motivation and eagerness to learn is noticed. The following statement was reported:. Hickman et al. Engaging students in applying evidence into professional practice is a critical role of nursing faculties. This results in student nurses gaining confidence in the use of research and EBP to inform decision-making.

Students also understood the difference between research and EBP and how one informs the other. Evidence-based practice allows for individualised care, improvement in quality care leading to quick recovery of patients and shortened period of hospitalisation which saves money for patients. Participants stated the following:.

When patient care is informed by sound evidence, it results in better and more affordable care towards people and the community. Nursing evolved from a series of dictated tasks to a holistic care approach which requires evidence that is developed into guidelines. These guidelines support nurses to promote individualised care Emmanuel et al. The use of EBP leads to improvement in the quality of care, thus reducing patient stay in hospital. Although quality is sometimes expensive, it comes with positive implications for health care facilities, for example, when patients receive quality care, their recovery is quicker and the numbers of days spent in hospital are reduced, resulting in reduction of patient-care costs.

Therefore, the employer and institutions benefit positively from the use of EBP because of the end result, which is improvement in the patient outcomes. One participant reported that:. For the health institutions to provide effective services, their functioning, planning, policies, and guidelines are informed by researched evidence. The following statements were reported:.

Reducing health care costs requires that nursing and health care services be based on best current available evidence. Improved cost-effectiveness of the health institutions allows the administrators the ability to negotiate for better sponsorship and incentives from health care funders and insurers Levin et al. Evidence-based practice teaching and learning is not explicitly implemented.

The current curriculum R does not have any specific guidelines for EBP teaching and learning; it only requires that research processes and steps to conduct research projects be taught to student nurses. The learner study guide only requires the nursing students to conduct and present a mini research project. There is no mention of EBP skills or competencies that must be acquired or achieved. The researchers concluded that the information generated as experiences of nurse educators is not directly linked to EBP in teaching and learning: it was more about teaching and learning of research in general.

Nevertheless, EBP depends for its success on researched information. Research is conducted to develop evidence that may be used for EBP. The utilisation of researched evidence in practice is known as EBP. It is never easy to separate research from EBP because one complements the other. However, it remains the responsibility of the NEIs to encourage student nurses to promote and deliver EBP from the onset of training; therefore, the principles of EBP should be introduced to students as part of pre-registration education Emmanuel et al.

Lack of resources was one of the challenges mentioned by most of the nurse educators, mainly the physical resources like lack of or poor access to computers and libraries. Non-availability of Internet access, current books, journals, and articles also contributed to poor access to relevant evidence needed for successful implementation of EBP teaching and learning. From the list of teaching strategies identified by nurse educators, it was clear that traditional teaching strategies are still dominant in nursing education.

Such strategies do not promote or stimulate critical-thinking skills and EBP competencies to student nurses. A teaching method is understood to be a particular technique a teacher uses to help learners gain the knowledge which they need and to achieve a desired outcome. A desired outcome in this context is the development of critical thinking, problem-solving and good decision-making skills for student nurses, which can be achieved by the use of EBP in teaching and learning as one of the innovative teaching strategies. Though it transpired that most nurse educators were supportive and had a positive attitude towards the implementation of EBP in teaching and learning, their level of knowledge and skills was questionable; there was uncertainty in understanding the use of EBP in teaching and learning; and a lack of motivation and commitment towards research was evident.

The findings revealed that nurse educators had positive attitudes towards EBP implementation. However, they demonstrated a lack of knowledge and skills in appraising and incorporating evidence into practice. Nurse educators cannot be expected to teach what is not known to them, therefore; they must be equipped with knowledge and skills so that they can teach EBP to produce professional nurses who are competent in evidence-based care Melnyk et al. It may not be possible to generalise the findings to all nurse educators because the study was limited to nurse educators who work in the public institutions under Umgungundlovu Health District, and who only provide R comprehensive 4-year programmes at two campuses.

Therefore, findings cannot be generalised to private institutions like universities, other districts, provinces or even nationally and for other nursing programmes. The current curriculum R should be reviewed and restructured to allow for early introduction of EBP principles at the onset of training. In addition, online and telematics studies together with the use of mobile technologies should be included in the curriculum. Relevant adequate resources should be made available and accessible to nurse educators and nursing students.

Access to sufficient clinical facilities that are appropriate for the achievement of the outcomes of the programme should also be considered. Nurse educators should be supported through in-service training, workshops and affiliation to journal clubs to improve their knowledge and skills regarding EBP competencies. The findings revealed both the challenges and benefits that come with the use of EBP in teaching and learning skills for the nursing education discipline, thus paving the way for the implementation of the suggested recommendations. Evidence-based practice has an essential potential role to play through incorporating more practice-based evidence of nurse educators in teaching and learning implementation.

Therefore, nurse educators should use EBP to ensure that student nurses receive high-quality nursing education. Thanks to Dr D. Habedi for her assistance and supervision in writing this article.

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I am also thankful to the participants for their willingness to contribute in the study. The authors declare that there are no competing interests with regard to the writing of this article. Boswell, C. Brink, H. Emmanuel, V. Felicilda-Reynaldo, R. Heikkila, J. Hickman, D. Hussein, A. Lehane, E. Leufer, T. Levin, R. Mackey, A. Malik, G.


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Mehrdad, N. Melnyk, B. Moule, P. Nursing research: An introduction , 2nd edn. Mthiyane, G. Polit, D. Schoonees, A. Spring, H. Subhan, M. Young, T. About the Author s Gloria N. Citation Mthiyane, G. Original Research. The experiences of nurse educators in implementing evidence-based practice in teaching and learning.

Gloria N.


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Mthiyane, Debbie S. Habedi Received: 26 Apr. Abstract Background: Nurse educators have a vital role to mentor student nurses in relation to developing evidence-based practice EBP skills, accessing research products and participating in research projects. Background Nurse educators play a key role in creation of opportunities for implementing EBP and in facilitating the implementation process. Purpose To determine the experiences of nurse educators in implementing EBP in teaching and learning, and to describe the importance and benefits of EBP in teaching and learning in the nursing profession, especially for nurse educators and student nurses.

Questions What are the experiences of nurse educators regarding implementation of EBP in teaching and learning? What recommendations may be made for nurse educators to implement EBP in teaching and learning? Two examples are used to examine the evidence base and potential synthesis or integration of preventive strategies in clinical and community settings that are implemented at multiple levels of influence in the social-ecological model.

In the first specific example, tobacco control, relevant information about effective clinical and community-level strategies is plentiful and interventions have been implemented at multiple levels contributing to improvements in important behavioral and possibly health outcomes. In the second example, obesity prevention and control, there are gaps in evidence regarding what works at each of the levels of influence and in the synthesis and integration of the evidence.

A Model for Implementing Evidence-Based Practices More Quickly - NEJM Catalyst

This example is presented to highlight the need for additional evidence as well as possibilities that exist for strategic coordination of preventive strategies. Coordinating Services on Multiple Levels. Tobacco use accounted for over , deaths per year in Table 1. Optimal success in reducing tobacco use prevalence has occurred when, in addition to clinical services, community-level interventions such as mass media efforts and legislation raising the price of tobacco products and reducing exposure to environmental tobacco smoke have been used, and quitlines have been made accessible and available.

Clinical Preventive Services. Community Preventive Services. It included:. Although funding for the MTCP program was withdrawn in , a special tobacco treatment program, QuitWorks, 22,23 still exists. QuitWorks coordinates clinical and community-based efforts by linking patients, clinicians, and a proactive telephone counseling quitline through the use of forms faxed to the quitline.

Funded by the Massachusetts Department of Public Health, it was created in collaboration with all the major health plans in the State. Studies have demonstrated the importance and feasibility of developing pathways or linkages between clinical settings and community-based settings. Although the MTCP did not set out to base its program on the recommendations of the USPSTF and the CTF, it did use a social-ecological framework to map out the types of services needed MTCP, unpublished document, and has contributed to the evidence base illustrating that complementary coordinated efforts are possible and that these efforts have beneficial effects.

Other studies and programs also have demonstrated that such coordinated efforts are possible and beneficial, and can work. While tobacco control has been largely a success story, there are still large gaps in utilization and application of clinical interventions in primary care settings. This is especially true where organizational, community and statewide programs, policies and resources are not available to support clinicians.

Obesity, a significant contributor to morbidity and mortality in the U. Sixteen percent of children and adolescents aged 6 to 19—over 9 million—are overweight BMI-for-age at or above the 95th percentile and the percentage of overweight children has tripled during the past decade. In contrast to the situation with tobacco, the available evidence regarding effective interventions to prevent obesity and promote weight loss in clinical and community settings is incomplete.

Programs, services, and guidelines needed to address obesity and weight loss are in an earlier stage of development than programs targeting the multiple levels of influence demonstrated to be effective in reducing tobacco use. The USPSTF found insufficient evidence to recommend for or against moderate- or low-intensity counseling with behavioral interventions for obese patients, or for screening and counseling overweight adults BMI or for routine screening for overweight in children and adolescents as a means to prevent adverse health outcomes.

The CTF has issued findings based on evidence available through on interventions in two community settings—schools and worksites—to promote healthy weight. A systematic review of published studies available through found that interventions in the worksite that combine nutrition and physical activity are effective in helping adult employees lose weight and keep it off in the short term. It determined there was insufficient evidence to recommend in favor of or against school-based programs for children and adolescents. In addition, the previous obesity reviews are being updated with new literature available since and new reviews are being conducted to include community and health care settings.

There are other potentially important interventions to influence healthy diet, nutrition, and physical activity related to agricultural and transportation policies, design of the built environment, and availability of affordable healthy foods, where data that meet CTF criteria are likely to be sparse, but where interventions have the potential to have large effects. The CTF has only begun to address these issues. As is the case with tobacco use, given the complex nature of obesity, coordinated interventions at multiple levels—from the primary care setting to the community—are likely to be needed to effectively prevent obesity and promote weight loss.

The CTF recommendations indicate that multi-component worksite programs that incorporate nutrition and physical activity interventions help adults control overweight and obesity, and that multiple strategies are available that have had success in promoting physical activity. Obesity is a significant and growing health problem and most communities will not wait for ideal information before taking action.

The challenge for communities is to implement programs in the face of the paucity of evidence regarding which interventions work; at a minimum this will require considering the evidence-based resources that exist and implementing them if they are consistent with community needs and resources, considering additional conceptually reasonable strategies, and acting at multiple levels in the social-ecological model.

Michael H. Kanter, MD

More obesity research is needed investigating interventions at each level of the social-ecological model and their potential incremental benefits as different combinations are used. This research can be included in future systematic reviews of program effectiveness so that better guidance through evidence-based recommendations can be provided to communities and practitioners. Integration of effective clinical and community-based strategies across the multiple levels of a social-ecological framework expands the availability of services at the levels of influence that may be most accessible to different individuals, thereby making utilization of available services more likely.

Increased utilization of services such as quitlines and community programs also makes it more likely that they will be more cost-effective and not disappear because of under- utilization. The tobacco case study demonstrates that effective clinical and community strategies can be developed, identified, and integrated, thereby increasing utilization and effectiveness. Approaches for linking clinical and community services include such things as computer linked systems where referrals are automatically made from a clinician to a community-based program and vice versa, or a fax referral system that links providers with community-based quitlines and vice versa.

Background

Obesity represents a continuing unmet challenge. Of the effective strategies available, questions remain as to which ones are feasible and cost effective. In order to facilitate integration of services in all areas of prevention there are key issues to consider. Substantial financial resources and policies are needed to transform existing or create entirely new systems that link resources into an efficient network.

Each requirement is a challenge at the clinical and community levels. Addressing the challenges requires leaders who are willing to advocate for creating and integrating effective clinical and community interventions, and for the financial resources and policies needed. Also needed are curricula for health professionals in which the value of a collaborative approach between clinical and community services to major health problems is strengthened. In health education curricula, the focus has largely been on expertise within the specialty discipline.

There is a growing recognition of the need to prepare health professionals to work collaboratively to plan, implement, and evaluate health strategies to target major health issues. The National Commission on Prevention Priorities adds important cost-effectiveness and magnitude-of-impact information to the evidence-based clinical services recommendations to guide decision-makers in setting priorities for policy-level actions. The ranking of clinical preventive services combined with information about their utilization in the population can be used to establish priorities to drive active translation efforts.

A similar initiative that compares the value of the population-based preventive services—that is, the cost effectiveness of interventions from the societal, individual, and health care system perspectives—could help policy makers determine the appropriate mix of clinical and population-based support for improving the health of the population. These priorities along with the evidence-based strategies to achieve them could be reflected in our forthcoming national health goals Healthy People Integration of delivery systems in the clinical and community setting is the next essential step.

Promoting the integration and collaboration of these well established and functioning systems preserves the strengths of the two systems and maximizes existing structures. The "Steps to a HealthierUS" Initiative The Department of Health and Human Services initiative, Steps to a HealthierUS, 33 funds 40 communities across the country to implement and evaluate chronic disease prevention projects focused on reducing the burden of diabetes, overweight, obesity, and asthma. Participating communities are working with health care providers and community-based organizations to strengthen the linkages between these two sectors.

The core of the program is based on the evidence-based recommendations of the CTF. The Steps to a HealthierUS initiative is being evaluated at the national and local levels. It is anticipated that the information gathered will help guide communities and clinicians in developing and implementing effective interventions and partnerships. Major improvements in health have occurred as a result of effective health care and clinical and community-based preventive interventions. Although the current burden of disease and injury remains high, improvements can be made through effective prevention strategies Table 2.

To continue the improvement in the health of the people in the United States we need to use the complete array of effective prevention tools at our disposal, increase their effectiveness and utilization by connecting them where possible, and systematically apply them at all levels of influence on behavior. Requests for linking or to incorporate content in electronic resources should be sent to: randie. Integrating evidence-based clinical and community strategies to improve health. Am J Prev Med ; Skip to navigation bar Skip to breadcrumbs Skip to page content.

Recommendations Published Final Recommendations. Information for Health Professionals. Information for Consumers. Nominate a Recommendation Statement Topic. Methods and Processes Procedure Manual. Standards for Guideline Development. Identifying Evidence Gaps. Conflict of Interest Disclosures. Table of Contents. Preface Judith K. Return to Table of Contents. Abstract Multiple and diverse preventive strategies in clinical and community settings are necessary to improve health.

This paper: Introduces evidence-based recommendations from the U. Examines, using a social-ecological model, the evidence-based strategies for use in clinical and community settings to address preventable health-related problems such as tobacco use and obesity. Advocates for prioritization and integration of clinical and community preventive strategies in the planning of programs and policy development, calling for additional research to develop the strategies and systems needed to integrate them.

Examples of use include the following: Recommendations made by the USPSTF form the core set of clinical preventive services that have been prioritized by the National Commission on Prevention. Work of the CTF has been used by Institute of Medicine IOM committees to inform national efforts to achieve and maintain high levels of immunization coverage; 8 and by public health programs e. Work of both Task Forces has contributed to the effective state and national efforts to reduce tobacco use 9 and is therefore considered fundamental to evidence-based cancer control.

The latter has caused an IOM committee addressing strategies to fulfill the potential for cancer early detection and control 10 to call for the U. Congress to provide sufficient appropriations to the U. Complementary Approaches to Prevention Although some problems of ill-health may be addressed in clinical or community settings, many are likely to benefit from the complementary and coordinated efforts of clinical and community-based interventions to address fully the opportunities for prevention. Social-Ecological Perspective Integration of complementary preventive services into a comprehensive package is consistent with a social-ecological perspective that recognizes that behaviors and health are influenced by multiple levels from the individual to families to larger systems and groups and then to the broadest levels at its rim, the population and ecosystem.

Case Studies Two examples are used to examine the evidence base and potential synthesis or integration of preventive strategies in clinical and community settings that are implemented at multiple levels of influence in the social-ecological model. In , the USPSTF recommended that: Clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products.

Clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke. It included: An innovative media campaign to change public opinion and community norms around tobacco use. Community mobilization to change local laws and health regulations. Comprehensive tobacco treatment programs based in clinics and community settings modeled after CDC and PHS guidelines to reduce tobacco use.

Offer obese patients—those whose BMI is equal to or greater than 30—intensive counseling and behavioral interventions to promote sustained weight loss. A high-intensity intervention was defined as one that offers more than 1 person-to-person individual or group session per month for at least the first 3 months of the intervention. There was insufficient evidence to determine whether some settings, persons, or teams were preferable to others in delivering these services. Refer obese patients to programs that offer intensive counseling and behavioral interventions for optimal weight loss.

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A Call for Integration of Clinical and Community-Based Strategies Integration of effective clinical and community-based strategies across the multiple levels of a social-ecological framework expands the availability of services at the levels of influence that may be most accessible to different individuals, thereby making utilization of available services more likely. Conclusion Major improvements in health have occurred as a result of effective health care and clinical and community-based preventive interventions.

Actual causes of death in the United States, JAMA ; 10 Correction: actual causes of death in the United States, JAMA ; 3 Methods for priority setting among clinical preventive services. Am J Prev Med ;21 1 Teutsch SM, Berger M. Evidence synthesis and evidence-based decision making: Related, but distinct processes editorial.

Med Decision Making ; Conceptualizing and combining evidence for health system guidance. Inferring strategies for disseminating physical activity policies, programs, and practices from the successes of tobacco control. The Future of the public's health in the 21st century. Calling the shots: immunization finance policies and practices.

Treating tobacco use and dependence. Clinical practice guideline. Fulfilling the potential of cancer prevention and early detection. Stokols D. Translating social ecological theory into guidelines for community health promotion.

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