Chapter 21 by Jennifer H. Bredemeyer and Ida M. Androwich Translational Research: Generating Evidence for Practice

Objectives Clarify the differences between evidence based practice and translational research. Describe models for introducing research findings into practice. Identify barriers to research utilization in practice.

Key Terms Defined Agency for Health Care Research http://www.ahrq.gov/ Context of Care Evidence Evidence Based Practice Agency for health Care Research (AHRQ) - An agency within the Department of Health and Human Services (HHS), that supports health services research initiatives. Context of Care - The setting, services, patient, environment, and professional and social interactions surrounding the delivery of patient interventions. Evidence - Artifacts, productions, attestations or other examples that demonstrate what an individual’s knowledge, skills or valued attributes. Evidence Based Practice - Nursing practice that is informed by research generated evidence of best practices. "The conscientious, explicit and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences” (Ingersoll, 2000, p. 152); integration of clinical expertise and best practices based on systematic research to enhance decision-making and improve patient care; "evidence-based nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences. Three areas of research competence are: interpreting and using research, evaluating practice, and conducting research” (Simpson, 2004, p. 10).

Key Terms Defined IOWA Model Meta-Analysis National Guideline Clearinghouse http://www.guidelines.gov/ Open Access Initiative IOWA Model - Model of Evidence-Based practice where research and other critically reviewed evidential sources are adopted, with the support and involvement of system resources, directly in the practice setting with the potential goal of developing a standard of care (Titler, 2007). http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/iowamodel.html Meta-analysis - A form of systematic review, uses statistical methods to combine the results of several studies (Cook, Mulrow, & Haynes, 1997). Quantitative studies are typically used. According to Glass (1976, p. 3) meta-analysis is “the statistical analysis of a large collection of analysis results from individual studies for the purpose of integrating the findings.” ;the best quality evidence since it utilizes multiple individual research studies to come to consensus. National Guideline Clearinghouse (NGC)- http://www.guidelines.gov/ A comprehensive database of evidentially based clinical practice guidelines and related documents which are regularly published through the NGC listserv and are available on the NGC website (National Guideline Clearinghouse, 2007). The NGC website allows users to browse the website for the clinical guidelines, view abstracts and full text links, download full text clinical guidelines to personal digital assistive (PDA) devices, obtain technical reports and compare guidelines. Open Access Initiative - A world wide movement to make a library of knowledge available to anyone with Internet access. Came about in response to the tremendous cost of research library access. Libraries pay large fees for journal subscriptions and the richness of library references are limited to what the budget allows. The cost of keeping current with research has caused library subscriptions to decline (Yoitis, 2005). Open access adds to the controversy with some journals charging authors for publications which in itself may provide a financial barrier to publication of this form.

Key Terms Defined Qualitative Study Quantitative Study Research Utilization Research Validity Qualitative Study - A type of research design that focuses on the human experience of a phenomenon using words, concepts, language and meanings rather than numbers to capture the essence of the subject under study. Looks at the why and how as it provides an indepth understanding of human behavior; allows us to understand the way in which the intervention is experienced to the researcher and to the participant as well as the value of the interventions to both parties (O'Neill, Jinks, & Ong, 2007). Qualitative research is not always considered in evidence-based practice, primarily due to the fact that methods for synthesizing the evidence do not currently exist. A method for synthesizing qualitative research is still being defined. The Cochrane Qualitative Research Methods Group (CQRMG-http://www.joannabriggs.edu.au/cqrmg/) is attempting to develop search, appraisal and synthesis methodologies for qualitative research. (Joanna Briggs Institute, n.d.) ; subjective. Quantitative Study - Research that looks at the what, where, and when to provide understanding of phenomena based on quantifying data and using statistical measures; depending on the research, can ascertain cause and effect relationships. Objective study. Research Utilization - The process of moving new understandings generated in research into practice. Research Validity -A conclusion that can be drawn about the conduct of the research based on an analysis of the research design and methods (internal validity) and the applicability of the findings to the general population (external validity).

Key Terms Defined Translational Research Translational Research - Research that is conducted with a vision toward transforming clinical nursing practice (translating into practice). The creation of a fluid sharing of research findings and clinical application of findings between research experts (who know) and clinical experts (who do), more meaningful research and improved application should result. This will close the gap between what we know (research) and what we do (practice).

Introduction Evidential Knowledge to Clinical Practice Evidence-Based Practice Research Utilization Translational Research The Importance of Research Evidence-based practice, translational research and research utilization are all words which have been used to describe the application of evidential knowledge to clinical practice. In evidence-based practice, the goal is to decrease practice variability, increase patient safety and eliminate unnecessary cost. Research utilization is a subset of evidence-based practice. Translational research is used to describe the translation of medical, biomedical, informatics and nursing research into bedside clinical interventions. Research results are crucial to furthering evidence-based practice.

Introduction The need for evidence Randomized Control Trial What constitutes evidence? Discussion abounds in the area of what constitutes evidence. Considered the most reliable, the randomized control trial (RCT) is often termed the gold standard for evidence. Evidence includes standards of practice, codes of ethics, philosophies of nursing, autobiographical stories, esthetic criticism, works of art, qualitative studies and the patient and clinical knowledge.

Determining Validity Research Must Be Valid Evidential Hierarchy 1. Meta-analysis 2. Individual experimental studies 3. Quasi-experimental studies 4. Non-experimental studies 5. Program evaluations such as quality improvement projects 6. Opinions of experts In order to use evidence in practice, the weight or validity of the research must be determined. An example of an evidential hierarchy by Stetler et al. (1998) prioritizes evidence into 6 categories: Meta-analysis Individual experimental studies Quasi-experimental studies Non-experimental studies Program evaluations such as quality improvement projects Opinions of experts

Clarification of Terms What is meta-analysis? What is the benefit of qualitative research? The hierarchy identifies meta-analysis as the best quality evidence since it utilizes multiple individual research studies to come to consensus. Qualitative research allows us to understand the way in which the intervention is experienced to the researcher and to the participant as well as the value of the interventions to both parties.

Bridging the gap between research and practice Barriers to the application of evidence-based practice An observational study performed by McKnight in 2006 How do nurses view the application of research? Bridging the gap between research and practice requires an understanding of the key concepts and barriers, accessibility to research findings, access to clinical mentors for research understanding, a reinforcing culture and a desire on the part of the clinician to implement best practices. Barriers to the application of evidence-based practice are lack of time, lack of access to libraries within their facility, lack of technology confidence, lack of knowledge on how to search for information and lack of value assigned to using research in practice. In an observational study of the information seeking behaviors of on-duty nurses, McKnight (2006) noted that nurses did not feel ethically comfortable with taking time from patient care to read publications, nor was much time available. Nurses may see the job of interpreting research as too complex or may see the organizational culture as a barrier to implementation.

The role of informatics The collaborative component of research The importance of technology The importance of an informatics infrastructure The integration of informatics and the medical record The collaborative component of research is supportive of informatics science. Technology has become so important to research that the National Institutes of Health has invested in re-engineering of the clinical research enterprise as part of its roadmap initiative for medical research (National Institutes of Health, 2007). An informatics infrastructure is critical to supporting a clinician’s access to information in a clinical setting. As an example of the integration of informatics and the medical record, Matter (2006) describes the positive effects of a successful integration of referential links with EBP clinical content in the clinical pathway on patient outcomes.

The role of informatics The Cochrane Collaboration http://www.cochrane.org/ Agency for Health Care Research http://www.ahrq.gov/ What is the mission of the AHRQ? The Cochrane Collaboration showed an increasing need to improve on the speed of knowledge acquisition and access to evidence. With the goal of promoting the use of research findings, and tool use based on these findings, the Agency for Health Care Research (AHRQ) became an active participant in pushing evidence forward into practice. The AHRQ is a government sponsored organization with the mission of reducing patient risk from harm, decreasing healthcare cost and improving patient outcomes through the promotion of research and technology applications focused on evidence-based practice.

The role of informatics Why was the National Guideline Clearinghouse created? What is the NGC (http://www.guideline.gov/) What are the benefits of NGC website? What resources are available for evidence-based practices? As part of an AHRQ initiative, the National Guideline Clearinghouse (NGC) was developed. NGC is a comprehensive database of evidentially based clinical practice guidelines and related documents which are regularly published through the NGC listserv and are available on the NGC website. The NGC website allows users to browse the website for the clinical guidelines, view abstracts and full text links, download full text clinical guidelines to personal digital assistive (PDA) devices, obtain technical reports and compare guidelines. There are a growing number of written and electronic resources available to assist in creating guidelines and offering information about evidence-based practice.

Developing evidence based practice guidelines Careful Analysis is Essential Information Technology also Plays a Very Important Role Careful analysis and discussion of the research and/or other forms of evidence in this scenario may reveal that given the organizational context, implementation may not be practical, or cost effective. Information technology is important in synthesizing the research regardless of the model.

Meta-analysis and Generation of knowledge What is the strength of the systematic review? What do systematic reviews achieve? What methods do meta-analysis use? What is meta-analysis? The strength of the systematic review is its ability to corroborate findings and reach consensus. Systematic reviews show the need for more research by revealing the areas where quantitative results may be lacking or minimal. Meta-analysis, a form of systematic review, uses statistical methods to combine the results of several studies. Meta-analysis is “the statistical analysis of a large collection of analysis results from individual studies for the purpose of integrating the findings

Meta-analysis and Generation of knowledge Steps of a meta-analysis are: 1. Defining the Problem 2. Establishing Study Eligibility 3. Identifying the Heterogeneity 4. Standardizing the Data 5. Sensitivity Testing Steps of a meta-analysis are: (1) defining the problem followed by protocol generation (2) establishing study eligibility criteria followed by literature search (3) identifying the heterogeneity of results of studies (4) standardizing the data and statistically combining the results (5)sensitivity testing to determine if the combined results are the same

Meta-analysis and Generation of knowledge What is the criticism of meta-analysis? How good is analysis? Where is information on meta-anlaysis available? The often sited criticism of meta-analysis is that emphasis is on quantitative studies, not qualitative. The analysis is only as good as the studies used in the analysis. Collection and dissemination of these meta-analysis and systematic reviews are available in paper and on-line through the internet, although many such databases require a subscription.

Meta-analysis and Generation of knowledge Where is open access available? What are open access journals? How do publishers of open access journals afford to provide free access to readers? What about the authors of open access journals? There are two vehicles for Open Access: (1) archives (2) journals Open Access journals are generally peer-reviewed and freely available. The publishers of open access do not charge the reader but obtain funds for publishing elsewhere. Open access journals may charge the author for publishing.

Thought Provoking Questions Twelve hour shifts are problematic for patient and nurse safety and yet hospitals continue to keep the 12-hour shift schedule. In 2004, the Institute of Medicine (Board on Health Care Services & Institute of Medicine, 2004) published a report which referred to studies as early as 1988 which discussed the negative affects of rotating shifts on intervention accuracy. Workers with 12 hour shifts realized more fatigue than workers on 8 hour shifts. In another study done in Turkey by Ilhan et al(Ilhan, Durukan, Aras, Turkcuoglu, & Aygun, 2006), factors relating to increased risk for injury were: age of 24 or less, less than 4 years of nursing experience, working in the surgical intensive care units and working for more than eight hours. As a clinician reading these studies, what would your next step be?

Thought Provoking Questions 2. The use of heparin versus saline to maintain the patency of peripheral intravenous catheters has been addressed in research for many years. The American Society of Health System recently Pharmacists (ASHSP) published a position paper in January 2006 (American Journal of Health System Pharmacists, 2006) advocating their support of the use of 0.9% saline in the maintenance of peripheral catheters in non-pregnant adults. It seems surprising that their position paper references articles that advocate the use of saline over heparin dating from 1991. What do you feel are some of the barriers which would have caused this delay in implementation?