Discussion Post On EBE: Read the article What’s in a Name and give a brief summarize the article and include…
Discussion Post On EBE
Read the article What’s in a Name and give a brief summarize the article and include any key points you find important and interesting.
Word count: 250 minimum – 500 maximum
References must be in APA format
EDUCATION
Nursing & Health Sciences Research Journal
Journal homepage: https://scholarlycommons.baptisthealth.net/nhsrj/
What’s in a Name: Performance Improvement, Evidence-Based Practice, and
Research?
Andrea Prentiss & Eve Butler
Keywords: performance improvement, evidence-based practice, research
Participants of the Institute of Medicine’s
Roundtable on Evidence-based Medicine have
identified that “by the year 2020, 90 percent of clinical
decisions will be supported by accurate, timely, and up-
to-date clinical information, and will reflect best
available evidence” as a goal (Institute of Medicine,
2009). The committee felt every American should have
as an expectation, at a minimum, this level of
performance with health care delivery. Using resources
already available to them, each organization should be
able to motivate and track their progress.
One of the challenges healthcare providers have in
meeting the IOM’s 2020 goal is a difficulty
differentiating between performance improvement
(PI), evidence-based practice (EBP), and research. The
terms performance improvement, evidence-based
practice, and research are frequently used inaccurately
and interchangeably with evidence-based practice
appearing to be the most misused of the three terms.
The common goal between PI, EBP, and Research
is to provide care to patients based on scientific
evidence and meet the patient’s needs. The final result
is the same; they all should lead to improving clinical
outcomes. Determining which process to use will be
defined by what one wants to know. Questions that
seek to answer a system issue, evaluate processes of
care, or improve care delivery are addressed using
quality improvement processes. Those that focus on
how well existing science is used in care are evidence-
based processes and those generating new knowledge
about under-explored areas are answered using
research methodologies. The purpose of this article is
to review the distinction between performance
improvement, evidence-based practice, and research.
PERFORMANCE IMPROVEMENT
The Centers for Disease Control and Prevention
(2015) indicated that hospitals use a variety of terms to
address similar principles (i.e., continuous quality
improvement, quality improvement, performance
improvement, six sigma, and total quality
management). Performance improvement (PI) is
comprised of systematic and continuous activities that
result in measurable improvement in health care
services and the outcomes of an identified group of
patients (Health Resources and Services
Administration, 2011). Donabedian (1966) proposed
three components of health care quality when evalua-
ting the quality of health care; structure, process, and
outcome. He defined structure as the settings,
qualifications of providers, and administrative systems
through which care takes place; the organization’s
resources. Process is defined as the components of care
delivered; how the system works and specific measures
for aspects of care. Outcome is defined as recovery,
restoration of function, and survival; the final product
or outcome. (Donabedian, 1966). These concepts
remain the foundation of quality assessment today.
There are several defined methodologies used to
conduct PI projects. Our organization most commonly
uses the plan, do, check, act or PDCA cycle which is
based on Demming’s PDSA (plan, do, study, act)
Model (The W. Edwards Deming Institute®, 2016).
This is a four-step model of facilitating change usually
depicted in a circle representing no end; it should be
repeated again and again for PI and monitoring
sustainability. The Agency for Healthcare Research and
Quality (2013) defines the steps in the PDSA cycle as:
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Prentiss and Butler: What’s in a Name: Performance Improvement, Evidence-Based Practic
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Step 1: Plan—Plan the test or observation,
including a plan for collecting data. In order to
determine what should be done to correct the problem
you would need to identify the problem and analyze the
problem determining the root causes.
Step 2: Do—try out the test on a small scale.
Identify recommendations by the team to correct the
problem. Put the plan into action on a small scale.
Collect data and track successes or make changes to the
plan as necessary.
Step 3: Check—set aside time to analyze the data
and study the results. The question you want to ask is,
has the improvement been sustained? If not further
actions may be required.
Step 4: Act—refine the change, based on what was
learned from the test. Communicate results to
stakeholders. If changes are required repeat the PDCA
cycle until the desired results are achieved.
The following is an example of a PI question. For
patients who develop a hospital acquired pressure ulcer,
was there consistent implementation of the skin care
protocol?
EVIDENCE-BASED PRACTICE
There are numerous definitions of evidence-based
practice (EBP) with most of them very similar.
Evidence-based practice has been defined as “a
science-to-service model of engagement of critical
thinking to apply research-based evidence (scientific
knowledge) and practice-based evidence (art of
nursing) within the context of patient values to deliver
quality, cost-sensitive care (2014 Magnet® Applica-
tion Manual, p. 67). Apel and Self (2003) describe
evidence-based practice as the marriage of research and
clinical services. It is about translating the evidence
and using it to make patient-care decisions
(Connor,2014). The majority of the best evidence
comes from the research; however, it may come from
patient/family preferences and values, clinical
expertise, and experts in the field.
Multiple EBP models are available to guide nurses
through implementation of an evidence based practice
change including the John Hopkins Nursing Evidence-
Based Practice Model (Dearholt & Dang, 2012), the
Iowa Model (Titler et al., 2001), and the Star Model of
EBP: Knowledge Transformation (Stevens, 2012).
Baptist Health South Florida (2011) has developed its
own model to guide practice changes, Clinical
Excellence Through Evidence-Based Practice
(CETEP). This model mirrors Sackett et al. (1996) five
steps to EBP and contains the necessary components to
be considered when making a practice change (Figure
1).
The CETEP model is comprised of five steps
which include:
Step 1: Define the clinical practice question. It is
important for nurses to formulate a searchable question
that focuses on the population of interest (P), the
intervention that you are interested in knowing more
about (I), a comparison intervention if applicable (C)
and lastly, the outcomes you hope to achieve (O).
Using PICO to guide your question development will
result in finding research applicable to your topic. An
example of a searchable question using the PICO
format is: For medical/surgical nurses (P) will
implementation of a pet visitation program (I) decrease
stress (O)?
Step 2: To assess the critical appraisal components.
Using the PICO question, the next step is to search for
and critically appraise the literature. The BHSF
medical library is a tremendous resource for nurses
wanting to make an EBP change. A request for a
literature search can be sent to the library staff using the
PICO question. Within 24-48 hours the library will
send a list of abstracts based on your PICO question.
From the abstracts you will select the most pertinent
articles and request from the library the full text article.
A systematic assessment of the research evidence is
then conducted to determine if the study is valid,
relevant to your setting, as well as what the results mean
for your population? The research then needs to be
combined to determine if they come to similar
conclusions supporting the EBP practice change. Once
the critical appraisal is completed, the next step is to
determine the applicability of the proposed practice
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https://norulesjustwords.files.wordpress.com/2012/10/pdca_cycle.png
Figure 1
Clinical Excellence Through Evidence-based Practice
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change with the other critical appraisal components in
the CETEP Model, patient factors, and clinical setting
factors. Research evidence alone is not enough to
justify a practice change.
Step 3: Develop a plan for the EBP change. In this
step you will obtain the necessary approvals to
implement the EBP change; determine what resources
will be needed; develop and implement a communication
and education plan; and identify how the process
change will be evaluated.
Step 4: Implement the practice change. Review
the plan and verify that support and resources are
available during this step to ensure success.
Step 5: Evaluate the outcomes of the evidence-
based practice change. Using the outcome measures
identified in the planning phase, review the practice and
invite feedback. Rephrase the question as needed
repeating the steps outlined above.
The following is an example of an EBP question.
For patients who develop a hospital acquired pressure
ulcer, would implementation of a turn clock tool as
compared to a turning team be a better method in
preventing pressure ulcers during hospitalization?
RESEARCH
Polit and Beck (2010) define nursing research as a
systematic approach to answering questions and
solving problems using a disciplined method based on
objective evidence. Its rigorous scientific inquiry
provides a significant body of knowledge to shape
health policy, advance nursing practice, and impact the
health of people across the globe (p.3). The primary
reason for conducting research is to expand the wealth
of knowledge for nursing to improve their patients care
and outcomes. Research enhances and validates
existing knowledge as well as generating new
knowledge (Burns & Grove, 2007). The results of
research creates a strong scientific base for nursing
practice (Melnyk & Fineout-Overholt, 2014); however,
a void still exists with nursing linking research and
practice.
Florence Nightingale is usually referenced as the
first nurse researcher as result of her work in the 1850s
surrounding morbidity and mortality of soldiers during
the Crimean War. Recognizing the correlation between
the environment and patient outcomes, her work led to
improved conditions and care of sick people (UT
Health, 2017). Nursing research is fundamental to the
nursing profession and is crucial for continuing
advancements that foster optimal nursing care. It
generates new, or expands on existing, knowledge
building the scientific underpinnings for clinical
practice. Regardless of the setting a nurse works in,
the primary goal remains the same: to be a patient
advocate and provide optimal care resulting in best
outcomes (Jane, 2015).
Nursing research is usually categorized as
quantitative, qualitative, or mixed methods.
Quantitative focuses on measurable outcomes, usually
analyzed with statistics whereas qualitative is based on
phenomenology or ethnography focusing on
experiences and analyzed with words. Research starts,
as all three processes do, with the identification of a
problem or question; what is it you want to know. One
then needs to determine the research goals, identify
what will be done, the methodology to conduct the
research, and then evaluating the results.
Developing the research question begins with an
idea, what is being questioned. This is also, as in EBP,
phrased using the PICO acronym. The research
question may be refined following the literature review
but the development of the PICO question ensures the
key words are present to help with the needed literature
review. A thorough literature review then needs to be
conducted in order to determine the existing knowledge
surrounding the topic, a gap in the literature, narrow the
research question, and determine the type of study to be
completed. Occasionally a study can be found that is
very similar to the one desired; it is perfectly acceptable
to replicate a study.
A quantitative study should have a research aim or
purpose, a hypothesis, independent and dependent
variables, instruments or scales to measure the
variables, and identified sample size, protection of
human subjects, and statistical analysis. Qualitative
studies involve similar steps but the data collection is
usually performed through interviews and
observations. There are four overarching types of
quantitative research: experimental, quasi-experimental,
descriptive, and correlational. Qualitative research,
focused on understanding the human experience, has
five main types of designs: phenomenology,
ethnography, grounded theory, historical method, and
case studies (Hunt, 2017). A conceptual framework or
theoretical model should be identified to help guide the
research process; these determine what you will
measure and the statistical relationships.
Included in the study methodology is the study
design, the sampling strategy, and data collection and
analysis. The research process includes a protocol and
application for Institutional Review Board approval.
The entire research process should be developed with
the entity nurse scientist.
The following is an example of a research
question. For patients who develop a hospital acquired
pressure ulcer, would implementation of a pressure
ulcer prevention bundle that includes patient
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participation, decrease the incidence of pressure ulcers
in hospitalized patients?
SUMMARY
In summary, PI is a formal approach to the analysis
of performance, unit based or entire hospital or system.
It is driven by data. It classically assumes that the
appropriate therapy or care is known but deviations
from the know standard has occurred and needs to be
identified and corrected. Changes are made in a
systematic manner, measuring and accessing the effects
of change, feeding the information back into the
clinical setting, and making adjustments until
successful results are obtained. The process is
continual, cyclical, in order to ensure positive achieved
outcomes continue.
Evidence-based practice is widely accepted by all
healthcare personnel desiring to base their care on
current evidence. Nurses are expected to have the
ability to develop, implement, and evaluate evidence.
Although the evidence-based practice model may
differ, the guidelines for use are similar: synthesis of
the evidence, consideration of where and how the
evidence is being implemented, and evaluation of the
process.
Research, the most rigorous of the three methods,
is a systematic approach to answering questions. It is a
disciplined method for solving problems based on
objective evidence and is designed to contribute to
generalizable knowledge. Institutional Review Board
approval must be granted before conducting the study.
Table 1 provides an overview of the differences
between performance improvement, evidence-based
practice, and research. Baptist Health South Florida is
fortunate to have many resources to assist those
attempting to understand and work with these three
processes. Library services will facilitate the literature
search obtaining abstracts and full articles upon
request. Additionally, each entity has a nurse scientist
who can also help differentiate what the project entails
and how to conduct it. Dissemination is the final step
in whichever process is conducted, whether at the unit
level or through a larger venue.
Table 1
Differences between PI, EBP, and Research
PI EBP Research
Purpose Improve patient care practices Change practice Generate new knowledge
Method PDCA
Short
Simplistic
Articles: Qualitative and
Quantitative
Expert opinion
Guidelines
Lengthy
Qualitative
Quantitative
Long
Complex
Sample Unit or organization Related to identified
population
Related to purpose and
research question
Representative
Data collection Short term
Action plan & evaluation
Critical appraisal of articles
Searching for best evidence
Ensure external and
internal validity,
trustworthiness
Long term
Human Subjects No IRB unless sharing
information externally
Assess IRB process
described in article
IRB
Results Seeks to improve processes in
unit and organization
Seeks to impact practice Seeks to add new
knowledge
Implications Change processes
Decrease cost
Increase efficacy
Increase patient and staff
safety
Improve satisfaction
Use of research to impact
process
Comprehensive
understanding of issues in
a phenomenon
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DECLARATION OF INTEREST
The authors report no conflicts of interest. The
authors alone are responsible for the content and
writing of the paper.
AUTHORS
Andrea Prentiss, PhD, MSN, ARNP, CNS, Nurse
Scientist, Baptist Hospital of Miami, Miami, FL, US.
Correspondence regarding this paper can be directed at
andreap@baptisthealth.net.
Eve Buttler, PhD, RN, Nurse Scientist, Baptist
Hospital of Miami, Miami, FL, US.
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