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Translational Research:
Generating Evidence for Practice
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Objectives
Clarify the differences between
evidence based practice andtranslational research.
Describe models for introducing
research findings into practice.
Identify barriers to research
utilization in practice.
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Introduction Evidence-based practice, translational
research and research utilization are all
words which have been used to describe
the application of evidential knowledge toclinical practice.
In evidence-based practice, the goal is to
decrease practice variability, increase
patient safety and eliminate unnecessarycost.
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Clarification ofTerms
Research utilization is a subset ofevidence-based practice.
Translational research is used todescribe the translation of medical,biomedical, informatics and nursingresearch into bedside clinical
interventions. Research results are crucial to
furthering evidence-based practice.
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Clarification ofTerms Discussion abounds in the area of what
constitutes evidence.
Considered the most reliable, the randomizedcontrol trial (RCT) is often termed the goldstandard for evidence.
Evidence includes standards of practice,codes of ethics, philosophies of nursing,
autobiographical stories, esthetic criticism,works of art, qualitative studies and thepatient and clinical knowledge.
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Clarification ofTerms In order to use evidence in practice,
the weight or validity of the researchmust be determined.
An example of an evidential hierarchyby Stetler et al. (1998) prioritizesevidence into 6 categories:
Meta-analysis
Individual experimental studies
Quasi-experimental studies
Non-experimental studies
Program evaluations such as quality improvementprojects
Opinions of experts
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Clarification ofTerms
The hierarchy identifies meta-analysis asthe best quality evidence since it utilizes
multiple individual research studies tocome to consensus.
Qualitative research allows us tounderstand the way in which theintervention is experienced to theresearcher and to the participant as wellas the value of the interventions to bothparties.
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Bridging the gap between
research and practice
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.
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Bridging the gap between
research and practice In an observational study of the
information seeking behaviors of on-
duty nurses, McKnight (2006) notedthat nurses did not feel ethicallycomfortable with taking time frompatient care to read publications, norwas much time available.
Nurses may see the job of interpretingresearch as too complex or may seethe organizational culture as a barrier toimplementation.
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The role of informatics 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 researchenterprise as part of its roadmap
initiative for medical research
(National Institutes of Health, 2007).
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The role of informatics
An informatics infrastructure is critical to
supporting a clinicians 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 linkswith EBP clinical content in the clinical
pathway on patient outcomes.
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The role of informatics
The Cochrane Collaboration showedan increasing need to improve on the
speed of knowledge acquisition andaccess to evidence.
With the goal of promoting the use ofresearch findings, and tool use basedon these findings, the Agency for
Health Care Research (AHRQ)became an active participant inpushing evidence forward intopractice.
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The role of informatics
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.
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The role of informatics
As part of an AHRQ initiative, theNational Guideline Clearinghouse
(NGC) was developed. NGC is a comprehensive database of
evidentially based clinical practiceguidelines and related documentswhich are regularly published throughthe NGC listserv and are available onthe NGC website(http://www.guideline.gov/).
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The role of informatics The NGC website allows users to browse the
website for the clinical guidelines, view
abstracts and full text links, download full textclinical guidelines to personal digital assistive(PDA) devices, obtain technical reports andcompare guidelines.
There are a growing number of written and
electronic resources available to assist increating guidelines and offering informationabout evidence-based practice.
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Developing evidence based
practice guidelines
Careful analysis and discussion of the
research and/or other forms of
evidence in this scenario may reveal
that given the context, implementation
may not be practical.
Information technology is important insynthesizing the research regardless
of the model.
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Meta-analysis and
Generation of knowledge
The strength of the systematic
review is its ability to corroboratefindings and reach consensus.
Systematic reviews show the
need for more research by
revealing the areas where
quantitative results may be
lacking or minimal.
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Meta-analysis and
Generation of knowledge
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 studiesfor the purpose of integrating the
findings.
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Meta-analysis and
Generation of knowledgeSteps of a meta-analysis are:
1. defining the problem followed by protocol
generation2. establishing study eligibility criteria followed by
literature search
3. identifying the heterogeneity of results ofstudies
4. standardizing the data and statisticallycombining the results
5. sensitivity testing to determine if the combinedresults are the same
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Meta-analysis and
Generation of knowledge The often sited criticism of meta-analysis
is that emphasis is on quantitative studies,not qualitative.
The analysis is only as good as thestudies used in the analysis.
Collection and dissemination of thesemeta-analysis and systematic reviews are
available in paper and on-line through theinternet, although many such databasesrequire a subscription.
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Meta-analysis and
Generation of knowledge There are two vehicles for Open Access:
archives
journals
Open Access journals are generally peer-reviewed and freely available.
The publishers of open access do notcharge the reader but obtain funds for
publishing elsewhere. Open access journals may charge the
author for publishing.
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Thought Provoking Questions1. Twelve hour shifts are problematic for patient and
nurse safety and yet hospitals continue to keep the12-hour shift schedule. In 2004, the Institute ofMedicine (Board on Health Care Services & Instituteof Medicine, 2004) published a report which referredto studies as early as 1988 which discussed thenegative affects of rotating shifts on interventionaccuracy. Workers with 12 hour shifts realized morefatigue than workers on 8 hour shifts. In anotherstudy done in Turkey by Ilhan et al(Ilhan, Durukan,Aras, Turkcuoglu, & Aygun, 2006), factors relating toincreased risk for injury were: age of 24 or less, lessthan 4 years of nursing experience, working in thesurgical intensive care units and working for morethan eight hours. As a clinician reading thesestudies, what would your next step be?
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Thought Provoking Questions2. The use of heparin versus saline to maintain the
patency of peripheral intravenous catheters hasbeen addressed in research for many years. TheAmerican Society of Health System recently
Pharmacists (ASHSP) published a position paper inJanuary 2006 (American Journal of Health SystemPharmacists, 2006) advocating their support of theuse of 0.9% saline in the maintenance of peripheralcatheters in non-pregnant adults. It seemssurprising that their position paper references
articles that advocate the use of saline over heparindating from 1991. What do you feel are some of thebarriers which would have caused this delay inimplementation?