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Strategy Submission

Using Evidence to Address Clinical Problems

Author:

Pamela M. Ironside

PhD, RN, FAAN

Title:

Associate Professor

Coauthors:

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Institution:

Indiana University School of Nursing

Email:

pamirons@iupui.edu

Competency Categories:

Evidence-Based Practice

Learner Level(s):

New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN, RN to BSN

Learner Setting(s):

Clinical Setting

Strategy Type:

Independent Study

Learning Objectives:

  • Differentiate clinical opinion from research and evidence summaries
  • Explain the role of evidence in determining best clinical practice
  • Identify gaps between local and best practice
  • Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences
  • Participate effectively in appropriate data collection and other research activities
  • Consult with clinical experts before deciding to deviate from evidence-based protocols.
  • Appreciate strengths and weaknesses of scientific bases for practice
  • Acknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices

Strategy Overview:

In this exercise, students work collaboratively to explore current practice on a unit where they are having clinical experience. In most cases, not every student will complete every phase. Rather, students will take turns investigating the problem and reporting results to the group. While this exercise describes only a part of the quality improvement process, you can expand it to be more inclusive as the timeframe and situation allows. Similarly, this exercise can span a few weeks or an entire semester. It is most helpful if the problem students explore is specific to the unit on which they are currently having clinical experiences so that they can look at their own practice over time as well as that of the staff. You may specify the problem in advance [i.e.: hospital acquired infections] based on your experience, or you may make the process of coming up with the problem part of the exercise [i.e.: after several weeks on the unit, students can collectively decide on a problem (potential problem) they have identified in the clinical setting]. Once the problem is identified, an assigned student investigates staff perceptions of the problem. [For instance, do staff see this as a problem? Why or why not? What initiatives have been tired (if any) by the unit staff to address or prevent it? Is this problem addressed at unit meetings/in-services?] Another student investigates the nursing literature related to the problem. [i.e.: Looking at the last 5 years, how many studies of this problem have been reported? What are the major conclusions?] Another student may look at the health literature more broadly [Who IS studying this problem? What does the literature recommend? How and in what ways does this relate to nursing?] Another student investigates the Cochrane Library and/or national benchmarks to gather evidence and recommendations for practice. Discussion throughout this part of the exercise focuses on the evidence related to the problem – where it is, how the problem is (or is not) being studied, and what questions remain for students. Simultaneously, another student may review charts on the unit to identify the extent of the problem (alternatively, each student may report relevant data related to the problem for their assigned patients and construct a simple database to look at incidence of the problem for their patients over time related to national data). As the exercise nears completion, discussion may include:
  1. When you think about the patients for whom you have been providing care this semester, what could possibly be wrong with the best evidence available to date?
  2. In what specific situation would you NOT use this evidence when planning care for this patient? Why?
  3. With whom would you consult (if anyone) in making this determination?
  4. Are there data sources that we have not yet explored that could be helpful in considering [this problem] or planning ways to alleviate it?
  5. What questions do you have (about this problem or nursing practice related to care of patients experiencing the problem) that aren’t being addressed by current researchers?

Submitted Materials:

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Additional Materials:

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Evaluation Description:

This exercise can be used for discussion or as a group project that is marked pass/fail. An important aspect of discussion is to engage students in thinking about the practical use of evidence in its most inclusive sense (i.e.: students immersed in exploring various data sources may inadvertently discount other valuable sources such as patient/family values and/or clinical expertise). As well, exploring what’s missing is a great time to talk about the importance of ongoing research and what to do when decisions must be made for which there is little, no, or conflicting evidence. Differentiating between valid and invalid reasons and the importance of backup from clinical experts can also help students explore the limits and boundaries of their current knowledge and experience.

Alternatively, you may ask each student to write and submit a one page summary of their findings which you can mark using a rubric consistent with those used at your school. (ie: A – work is clear, complete and concise, demonstrates excellent command and critical use of resources related to [the problem]. B – work is clear and concise, reflects consistent and appropriate use of resources related to [the problem]. C – work is incomplete and reflects non-critical or superficial use of resources). The questions at the end, however, should be for discussion only.

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