Diffusing Confusion Among Evidence-Based Practice, Quality Improvement, and Research Robin Purdy Newhouse, PhD, RN, CNA, CNOR

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JONA Volume 37, Number 10, pp 432-435 Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diffusing Confusion Among Evidence-Based Practice, Quality Improvement, and Research Robin Purdy Newhouse, PhD, RN, CNA, CNOR

In this department, hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator are highlighted. The goal is to dis- cuss the practical implications for nurse leaders in diverse health- care settings. Content includes evidence-based projects and deci- sion making, locating measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, prac- tice implications of administrative research, and exemplars of proj- ects that demonstrate innova- tive approaches to organizational problems.

In a recent evidence-based practice (EBP) workshop, a nurse executive asked: ‘‘What is the difference between EBP and quality improve- ment (QI) and benchmarking?’’ In a different workshop, another asked: ‘‘Do I need an institutional

review board approval for my EBP project?’’ It becomes confus- ing when organizational EBP, QI, and research activities are all re- ferred to as EBP. The issue is that these activities often overlap. This column assesses the unique and overlapping relationships among EBP, QI, and research. Defi- nitions are provided in Figure 1. Using an organizational problem of increased pressure ulcer rates, examples of each approach are provided in Figure 2.

Research Research is a systematic investiga- tion, including research develop- ment, testing, and evaluation designed to develop or contribute to generalizable knowledge.1 Be- cause nursing research is under- developed in a number of areas, scientific evidence (research) is not available to inform practice when a problem emerges or questions are raised about nursing processes included in organizational policies.

The research process includes identification of the problem, selection of a conceptual frame- work or theoretical model that describes the relationships be- tween study variables, generation

of hypotheses or research ques- tions, and a plan for the study design and method. The design and method are based on the state of knowledge of the prob- lem and the gap in the evidence.

The design frames the appro- priate research approach (experi- mental, quasi-experimental, or nonexperimental). The sample consists of the number and type of subjects needed to identify a statistically significant difference if one exists. The method includes appropriate controls, including mea- sures or instruments with adequate estimates of reliability and valid- ity. Standard research procedures are established that include a plan for interventions, measurement, data collection, and statistical analysis. Institutional review board approval is obtained before implementation of the research protocol.

The design and methods of research seek to control as many variables as possible so that a link is established between the inter- vention (or concept of interest) and effect (or outcome). Using a well-planned and implemented research approach to solve a clini- cal, administrative, or education

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Author Affiliation: Associate Profes- sor and Assistant Dean, Doctor of Nurs- ing Practice, University of Maryland, School of Nursing, Baltimore, Maryland.

Correspondence: University of Mary- land, School of Nursing, 655 W. Lombard Street, Room 516B, Baltimore, MD 21201- 1579 (newhouse@son.umaryland.edu).

 

 

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problem informs decisions in healthcare organizations, extend- ing beyond lessons learned in one organization, to generalizable knowledge that can be applied in similar settings.

Quality Improvement

Quality improvement is a process by which individuals work to- gether to improve systems and processes with the intention to improve outcomes.2 An alterna- tive definition is that QI is a data- driven systematic approach to improving care locally.3 The dis- tinction between research and QI has been recently reviewed, defined, and debated.3-5

One familiar framework to guide the QI process is plan-do- study-act.6 Examples of ap- proaches to data presentation from QI efforts include control, radar, Pareto charts, and cause- and-effect diagrams.7 Although approaches to QI have undergone an evolution to improve the sys-

tematic approach, publications of results are usually limited to les- sons learned, instead of general- izable results. In addition, there has been an increase in investiga- tors who conduct health services research with their research activi- ties focused on QI interventions. These investigators intend to gen- eralize results and approach the organizational improvement inter- vention as a research study.

Evidence-Based Practice

An often-cited landmark defini- tion of EBP is: ‘‘Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of indi- vidual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.’’8(p71)

This definition is appropriate for nursing research utilization,

but insufficient for EBP because the best evidence available to address nursing problems is often not research. In addition, nursing practice is nested within organi- zations, and appropriate organi- zational infrastructure fosters system and individual uptake and use of evidence. The defini- tion of EBP can be expanded to the following: EBP is a problem- solving approach to clinical deci- sion making in a healthcare organization that integrates the best available scientific evidence with the best available experien- tial (patient and practitioner) evidence, considers internal and external influences on practice, and encourages critical thinking in the judicious application of such evidence to care of the individual patient, patient popu- lation, or system.9 Note that this approach uses the best available evidence, not one source of evi- dence that supports current prac- tice. A rigorous search strategy is used, followed by retrieval and review of evidence that includes grading the strength and quality, and then applying the results through implementation and evaluation of the recommenda- tions. This definition includes the organization’s experience.

Experiential evidence ex- tends beyond the individual pro- vider or patient, to activities such as QI, benchmarking, or organizational or program out- come monitoring. Rycroft-Malone et al10 call this organizational evidence ‘‘local context’’ and suggest that far more work is needed to understand how this type of evidence is collected and incorporated with other types of evidence to inform healthcare decisions.

Figure 1. Definitions.

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The Overlapping Relationships

Research and QI (as a form of experiential evidence) both in- form EBP. Research provides a higher level of evidence than QI and is the major source of evi- dence in the medical discipline. Quality improvement provides real-life experience and descrip- tive data within the context of the organization, making the rapid cycle approach and evalua- tion of outcomes very actionable.

However, there are 2 major problems with using QI data as a source of evidence.11 First, usu- ally, the QI process does not meet fundamental standards for the conduct or publication of research.

Second, the interventions used in QI processes often are not based on theory that predicts their success. These deficiencies in the QI process produce results that are not transferable to other organizations (generalizable) and do not measure variables or data that are needed to explain the results, designs that lack the ability to draw causal inferences, and a number of additional weaknesses (threats to internal validity).

Research and EBP processes both inform QI. When develop- ing strategies to improve outcomes in QI initiatives, research evidence is reviewed, and an intervention or interventions are selected to im-

prove the likelihood of success for the change. Individual research studies may be used to inform QI action, as well as the recommen- dations from an EBP evidence review. The evidence review may contain scientific (such as experi- mental studies) or experiential (such as consensus or expert opin- ion) sources. Scientific evidence (research) provides a higher level of generalizability or application to similar settings than experien- tial evidence.

Evidence-based practice and QI both inform opportunities for research. As the team evalu- ates the QI outcomes and les- sons learned in their rapid cycle

Figure 2. Examples of research, QI, and EBP.

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improvements, they may iden- tify descriptive improvements in areas where there are gaps in the evidence to support the need for research to test a new inter- vention. Likewise, during the evidence review and synthesis phase of the EBP process, gaps in knowledge are identified. These gaps provide the opportu- nity to generate research ques- tions or hypothesis and design a research study to measure the association or differences between variables.

Conclusion Major forces drive the need for nurses to demonstrate basic and advanced competency in EBP, QI, and research. These forces include disparities and deficits in quality of care for patients, in- creasing evidence to support the effectiveness of interventions, national efforts to standardize performance measures, and a focus on improving the health- care work environments.

Efforts to improve work environments necessitate that we apply evidence to healthcare de- livery, align payment policies with QI, and prepare the work- force.12 Applying evidence to practice requires that we apply scientific knowledge systemati- cally, building infrastructure to support decision making, setting goals for improvement, and de- veloping measures to assess qual- ity.12 Preparing the workforce involves developing competencies in QI, EBP, informatics, patient-

centered care, and interdisciplinary collaboration.13

To advance quality, an inter- disciplinary common vision, lan- guage, and processes are required. Research, QI, and EBP are tools to identify and describe problems, explain relationships between fac- tors of interest, and implement interventions or strategies with a clear rationale. Nurse executives have an important role in diffus- ing the confusion between EBP, QI, and research; building collabo- rative relationships; and establish- ing organizational infrastructure to support continued improvements in healthcare quality.14,15 A precur- sor to leading is understanding the distinct differences, yet overlap- ping associations, between these 3 important activities.

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