TEST BANK for Evidence-Based Practice for Nursing and Healthcare Quality Improvement by Wood Geri Lo by StudyGuide

Chapter 01: Overview of Evidence-Based Practice LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition MULTIPLE CHOICE

1. The first step in the evidence-based process is to a.

form a team of health care providers.

retrieve evidence.

select an EBP topic.

critically appraise evidence.

ANS: C

The steps for EBP are: select an EBP topic, form a team, evidence retrieval, critical appraisal of evidence, evidence synthesis, set forth EBP recommendations, decision to change practice, convey EBP recommendations to local standards, policies or procedures, implement practice change, evaluation, and dissemination. 2. Which agency is the National Guideline Clearinghouse of publicly available database of evidence-based clinical practice guidelines

and related documents? a.

The Institute for Healthcare Improvement (IHI)

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)

The United States Preventative Services Task Force (USPSTF)

The Agency for Healthcare Quality and Research (AHRQ)

ANS: D

AHRQ provides a variety of EBP function including serving as the National Guideline Clearinghouse: publicly available database of evidence-based clinical practice guidelines and related documents. Updated weekly with new content, NGC provides an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines to further dissemination, and implementation. Examples of IHI Evidence-Based Standards or Recommendations include development of a patient and family-centered ICU, Communication about end-of-life care, the opioid crisis and building systems of safety. Examples of JCAHO Evidence-Based Standards or Recommendations include fall prevention, patient/family education, prevention of CAUTI, and prevention of medication errors. The USPSTF assigns recommendations for prevention and evidence-based health care a letter grade (an A, B, C, or D grade or an I statement) based on strength of the evidence and balance of benefits and harms of a preventive service. The Task Force does not consider costs of a preventive service when determining a recommendation grade. 3. Which of the following statements comparing evidence-based practice to the conduction of research is true? a.

EBP poses research questions or hypotheses that advance the state of the science.

The purpose of EBP is to gain knowledge/science generation.

Standardized-dependent measures with known reliability and validity are used as evaluation methods for EBP.

EBP evaluation includes quality improvement metrics that address both processes of care and patient outcomes.

ANS: D

Conduct of research poses research questions or hypothesis that advance the state of the science. The purpose of an EBP clinical question or purpose of the EBP project is derived from the PICO. Application of research findings and/or other evidence in local practice and/or communities is another purpose of EBP. Standardized-dependent measures with known reliability and validity are used as evaluation of conduction of research. 4. Which of the following is an example of an evidence-based practice approach? a.

Smoking cessation reports from participants for 6 months prior to implementation, mid-way during implementation (3 months), and following implementation of a “Stop Smoking” program

Comparison of blood pressure in one group who walk 20 minutes a day/5 days a week versus another group who are sedentary

Measuring heart rate on volunteers who listen to music prior to sleep versus volunteers who do not listen to music prior to sleep

Comparison of patient satisfaction scores from two medical surgical units over a

3-month period ANS: A

The approach in EBP is a nonresearch design. For a specific period of time measures are tracked pre-implementation, during implementation, post-implementation. The other responses are examples of the conduct of research approach which is aligned with the research questions/hypotheses (e.g., observational; RCT; step-wedge design).

5. Which of the following is the best description of translational research? Translational research a.

is the systematic investigation of a phenomenon to answer research questions or hypotheses that advances the state of the science.

focuses on the generation and synthesis of evidence that compares benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition, or to improve the delivery of care.

is a dynamic continuum from basic research through application of research findings in practice, communities, and public health settings to improve health and health outcomes, progresses across five phases.

is a field of science that focuses on testing implementation interventions to improve uptake and use of evidence to improve patient outcomes and population health, and explicate what implementation strategies work for whom, in what settings, and why.

ANS: C

Conduct of research is the systematic investigation of a phenomenon to answer research questions or hypotheses that advances the state of the science. Comparative effectiveness research (CER) focuses on the generation and synthesis of evidence that compares benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition, or to improve the delivery of care. Implementation science (also called translation science) is a field of science that focuses on testing implementation interventions to improve uptake and use of evidence to improve patient outcomes and population health, and explicate what implementation strategies work for whom, in what settings, and why. 6. Which statement regarding evidence-based practice is true? a.

The nursing profession is the sole contributor and user of EBP.

Evidence-based practice and conduct of research have distinct purposes, questions, approaches, and evaluative measures.

Teams working with EBP should consist of only health care providers.

EBP and translation science are interchangeable terms.

ANS: B

Participation in and contribution to EBP is essential for many professionals to plan, provide, and evaluate optimal care. The application of evidence to improve quality of care and patient outcomes is central to health care improvement. The national agenda for EBP is clearly in the forefront of health care. When considering members of the EBP team, consideration should be given to including lay-persons who have experience with the selected topic. Involving consumers may increase their understanding of why certain EBPs are used in what circumstances and why they are important. EBP and translation science are not interchangeable terms. Translational science is a dynamic continuum from basic research through application of research findings in practice, communities, and public health settings to improve health and health outcomes, progresses across five phases. 7. Leaders of health care systems have an opportunity to promote an organizational culture that makes evidence-informed leadership

decisions, and creates evidence-based practice environments to promote high quality, safe patient care by doing which of the following? a.

Creating and enacting an organizational mission, vision, and strategic plan that incorporates evidence-based practice

Developing and implementing performance expectations for all staff that include evidence-based practice work

Integrating the work of evidence-based practice into the governance structure of the health system

All of the above

ANS: D

Evidence is now available for a variety of topics to inform leadership and administrative decision-making (e.g., staff turnover, staff performance, optimizing staffing patterns). Therefore, the leaders of your health care system have an accountability to promote an organizational culture that makes evidence-informed leadership decisions, and creates evidence-based practice environments to promote high quality, safe patient care. This includes: creating and enacting an organizational mission, vision, and strategic plan that incorporates EBP; developing and implementing performance expectations for all staff that include EBP work; integrating the work of EBP into the governance of the health system; role modeling the value of EBP through administrative behaviors; and establishing explicit expectations that nurse leaders create microsystems that value and support clinical inquiry. 8. Expectations of doctoral prepared nurses in the area of evidence-based practice include

development, implementation, and evaluation the effect of EBP programs at the organization and system levels.

design, direct, and evaluate quality improvement methodologies to promote safe, timely, effective, efficient, equitable, and patient-centered care.

explication of the return on investment of EBP.

All of the above

ANS: D

Nurses with doctorates of nursing practice (DNPs) are expected to: be experts in EBP; possess the knowledge and skills of Master’s prepared nurse’s as well as being knowledgeable about the latest evidence for their patient populations; developing, implementing, and evaluating the effect of EBP programs at the organization, and system level; designing, directing, and evaluating quality improvement methodologies to promote safe, timely, effective, efficient, equitable, and patient-centered care; explicate the return on investment of EBP; negotiate systems changes that foster practice climates for EPB; negotiate systems changes that foster practice climates for EBP; and role model knowledge and skills of EBP.

9. The first step of EBP is? a.

Topic selection

Evodence synthesis

Form a team

Evidence retrieval

ANS: A

EBP steps include: select an EBP topic, form a team, evidence retrevial, critical appraisal of the evidence, evidence synthesis, set forth evidence-based practice reommendtions, decision to chage practice, convert EBP recommendations into local standards policie or procedures, implement the practice chge, evaluation, and dissemination.

10. Which of the following were seminal projects that laid the groundwork for application of research findings in practice to improve

patient care, known today as evidence-based practice (EBP)? a.

Western Interstate Commission for Higher Education in Nursing (WICHEN) regional program on nursing research development

Nursing Child Assessment Satellite Training project (NCAST)

Moving New Knowledge into Practice Project

All of the above

ANS: D

Seminal projects that laid the groundwork for application of research findings in practice to improve patient care, known today as evidence-based practice (EBP) include: Conduct and Utilization of Research in Nursing (CURN) project, Western Interstate Commission for Higher Education in Nursing (WICHEN) regional program on nursing research development, Nursing Child Assessment Satellite Training project (NCAST), Moving New Knowledge into Practice Project, and Orange County Research Utilization in Nursing Project. 11. Evidence-based practice involves a.

the systematic investigation of a phenomenon to answer research questions.

a hypothesis that generates new knowledge and advances the state of the science.

conscientious and judicious use of current best evidence in conjunction with clinical expertise, patient values, and circumstances to guide health care decisions.

use of tools to collect data with demonstrated reliability and validity.

ANS: C

Evidence-based practice and conduct of research have distinct purposes, questions, approaches, and evaluation methods. Conduct of research is the systematic investigation of a phenomenon to answer research questions or hypotheses that generate new knowledge and advance the state of the science. Randomized controlled trials are often evaluated in conduct of research aiming to advance science. Tools with demonstrated reliability and validity are used to collect and compare data. Findings of conduct of research are often disseminated at scientific conferences and in scientific journals. 12. Which of the following is not a component of structure-process-outcome? a.

Structure

Process

Outcome

Hypothesis

ANS: D

Components of structure-process-outcome include: structure—the physical and organizational components of care delivery such as facilities, equipment, and staffing, process—services and treatments patients receive, and outcomes—effect that the processes of care have on patients and populations. Hypothesis development and evaluation is a component of conduct of research.

TRUE/FALSE

1. Members of evidence-based practice teams should consist solely of practicing health care providers?

ANS: F

The composition of an EBP team varies on the question being asked, the patient population, and the anticipated resources needed. Potential EBP teams can be comprised of a broad array of health professionals including, but not limited to nurses, nurse

practitioners and midwives, physicians, physician assistants, social workers, pharmacists, as well as occupational and physical therapists. Other potential members who have important contributions to make such as QI specialists, staff from infection control or finance, health science librarians, or IT support staff may be considered. Depending on the patient population and practice setting, point-of-care providers such as care coordinators, patient navigators, and community health workers also may offer important contributions to the EBP Team. Consideration should be given to including a lay-person who has experience with the topic on the EBP team. Lay-people can lend their expertise as recipients of health care and provide input into practices important to them. Involving consumers may increase their understanding of why certain EBPs are used in what circumstances and why they are important. Consumers may be helpful in championing the use of EBPs, and consumers may provide insights into evaluation components of EBP. 2. Despite the availability of evidence-based recommendations for practice, the 2014 National Healthcare Quality and Disparities

Report demonstrated that evidence-based care is delivered only 70% of the time? ANS: T

Despite the availability of evidence-based recommendations for practice, the 2014 National Healthcare Quality and Disparities Report demonstrated that evidence-based care is delivered only 70% of the time, an improvement of just 4% since 2005.

3. Nursing research began in the 1970s.

ANS: F

Nursing research was pioneered by Florence Nightingale in the mid-1800s. Nightingale used data to change practices that contributed to high mortality rates in hospitals and communities. 4. When planning for implementation of evidence-based practice, the value of the EBP practice topic as perceived by users and

stakeholders is the only factor which determines the rate and extent of adoption. ANS: F

When planning for implementation of EBPs, it is not just the importance or value of the evidence-based practice topic as perceived by users and stakeholders that will influence their adoption. It is the interaction among the characteristics of the evidence-based practice topic, the intended users, and a particular context of practice that determines the rate and extent of adoption. 5. Quality improvement emphasizes customer satisfaction, teams and teamwork, and the continuous improvement of work processes.

ANS: T

Quality improvement (QI) is both a philosophy of organizational functioning and a set of analysis tools and change techniques to reduce variations in the quality of care provided by health care organizations. QI emphasizes customer satisfaction, teams and teamwork, and the continuous improvement of work processes. Other defining features include: setting organizational performance goals and expectations, use of data to make decisions, and standardization of work processes to reduce variation across providers and service encounters. 6. Evidence-based practice is a type of quality improvement that focuses on implementing evidence-based processes of care to

improve patient outcomes and population health. ANS: T

Evidence-based practice is a type of quality improvement that focuses on implementing evidence-based processes of care to improve patient outcomes and population health. 7. Translational science provides a scientific base for guiding the selection of implementation strategies to promote adoption of

evidence-based practice in real-world settings. ANS: T

Translational science provides a scientific base for guiding the selection of implementation strategies to promote adoption of evidence-based practice in real-world settings.

Chapter 02: Models and Evidence LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. Which of the following is an example of a problem-focused trigger? a.

How often should a patient ambulate after abdominal surgery to prevent pneumonia?

How often should blood glucose monitoring be recorded for a non-diabetic patient receiving total parenteral nutrition?

How long should a patient be maintained on nothing by mouth status after endotracheal extubation?

Should patients with acute coronary syndrome wear sequential compression hose to prevent deep vein thrombosis?

ANS: D

Problem-focused triggers are those identified by staff through quality improvement, risk surveillance, benchmarking and financial data, or recurrent clinical problems. Knowledge-focused triggers arise when health providers hear scientific presentations, read research articles, or published evidence-based practice guidelines and question practice. 2. Which of the following are clinical questions derived from the problem? a.

Therapy

Harm

Diagnosis

Prognosis

Meaning

All of the above

ANS: F

There are five types of clinical questions derived from the problem: therapy—question focuses on determining the effect of an intervention(s) on patient outcomes; harm—question focuses on the potential harm of a symptom or group of symptoms, disorder, treatment, or intervention; diagnosis—question focuses on the establishment of the power of a test to differentiate between those with the disease or problem and those who do not experience the problem; prognosis—question focuses on a patient’s likely course for a disease state or factors that may alter a prognosis; meaning—question focuses on the situation or processes related to how people experience, cope or adapt to conditions, illnesses, or circumstances. 3. Which of the following questions should be considered when identifying key stakeholders for an evidence-based practice team? a.

Who is likely to lead and champion implementation of the practice?

Who can influence the decision to proceed with implementation of the practice, either positively or negatively?

What type of cooperation is needed from stakeholders for the practice change to be successful?

All of the above

ANS: D

Questions to consider in identification of key stakeholders include: How are decisions made in the area where the evidence-based practice will be implemented; What types of unit or system changes will be needed; Who is involved in decision-making; Who is likely to lead and champion implementation of the practice; Who can influence the decision to proceed with implementation of the practice, either positively or negatively; What type of cooperation is needed from stakeholders for the practice change to be successful? 4. Which of the following is not a component of the PICO Model? a.

Population

Intervention

Cash flow

Outcome

ANS: C

Components of the PICO Model include P—patient, population, problem; I—intervention, prognostic factor, exposure; C— comparison or intervention; and O—outcome you would like to measure or achieve. 5. In most evidence hierarchies, which of the following study types is considered to be the top of the pyramid and to be more rigorous

and hence more likely to minimize the effect of bias on the results of the study? a.

Expert opinion

Systematic reviews

Randomized controlled trials

Case controlled studies

ANS: B

Systematic reviews are considered to be at the top of the pyramid in most evidence hierarchies and are a more rigorous methodology and hence more likely to minimize the effect of bias on the results of the study. The order then follows randomized controlled studies, case controlled studies, and expert opinion.

6. Before critically appraising research, it is suggested to read/critique which types of the following articles first? a.

Clinical and theory articles to understand the state of the practice and theoretical perspectives and concepts that may be encountered in critiquing studies

Meta-analyses, systematic and integrative reviews to understand the state of the science

Evidence-based practice guidelines and evidence reports

Research articles

ANS: A

It is helpful to read/critique articles in the following order: (1) clinical and theory articles to understand the state of the practice and theoretical perspectives and concepts that may be encountered in critiquing studies; (2) meta-analyses, systematic and integrative reviews to understand the state of the science; (3) evidence-based practice guidelines and evidence reports; (4) research articles. 7. A group approach to critical appraisal is recommended because a.

the leader assumes most of the workload.

those responsible for implementing the changes have an opportunity to understand the scientific base for the practice change.

financial-based information is obtained to advocate for the change.

the group is composed of experienced individuals which saves valuable time.

ANS: B

A group approach to critical appraisal is recommended because it distributes the workload, helps those responsible for implementing the changes to understand the scientific base for the practice change, arms nurses with citations and research-based language to use in advocating for changes with peers and other disciplines, and provides novices with an environment to learn critical appraisal and application of research findings. 8. Factors to consider in the synthesis of findings include all of the following except a.

overall scientific merit.

relevance of the study to the question topic.

incorporation of findings to current policies and procedures.

comparison of types of subjects enrolled and their similarity to the patient population to which the findings will be applied.

ANS: C

Factors that should be considered for inclusion of studies in the synthesis of findings include: overall scientific merit; type of subjects enrolled (e.g., age, gender, pathology) and the similarity to the patient population to which the findings will be applied; as well as relevance of the study to the question topic. 9. Essential information to include in a summary table consists of which of the following? a.

Research questions/hypotheses

Independent and dependent variables studied

Description of the study sample and setting

Type of research design

Methods used to measure each variable and outcome

All of the above

ANS: F

Essential information to include in a summary table consist of: research questions/hypothesis; independent and dependent variables studied; description of the study sample and setting; type of research design; methods used to measure each variable and outcome; study findings as well as strengths and weaknesses of each study.

TRUE/FALSE

1. The EBP process uses a clinical question to search the published literature for completed studies in order to bring about

improvements in care? ANS: T

EBP process uses a clinical question to search the published literature for completed studies in order to bring about improvements in care.

2. Translation science focuses on testing the implementation of interventions to improve uptake and use of evidence to improve

patient outcomes and population health, as well as to clarify what implementation strategies work for whom, in what settings, and why. ANS: T

Translation science focuses on testing the implementation of interventions to improve uptake and use of evidence to improve patient outcomes and population health, as well as to clarify what implementation strategies work for whom, in what settings, and why. 3. Problem-focused triggers arise when health care providers hear scientific presentations, read research articles, or published

evidence-based practice guidelines and question practice. ANS: F

4. A stakeholder is a key individual or group of individuals who will be directly or indirectly affected by the implementation of the

evidence-based practice. ANS: T

A stakeholder is a key individual or group of individuals who will be directly or indirectly affected by the implementation of the evidence-based practice. 5. When forming an evidence-based practice team, resistors to the change may be valuable members to include.

ANS: T

Stakeholders who can facilitate an evidence-based practice project or create barriers that preclude successful implementation should be identified. Some of these stakeholders may be members of the team. Others may not be team members but are key individuals within the organization or unit who can adversely or positively influence the adoption of the practice. 6. It is suggested that evidence retrieval be completed prior to the PICO process.

ANS: F

Relevant research and related literature need to be retrieved after a clinical question (PICO) is developed. 7. There is no consensus among professional organizations or across health care disciplines regarding the best system to use for

grading the type and quality of research evidence. ANS: T

There is no consensus among professional organizations or across health care disciplines regarding the best system to use for grading the type and quality of research evidence. 8. The first step in grading the evidence of a study is to identifying the level of evidence according to the design of the study.

ANS: T

The first step in grading the evidence of a study is to identifying the level of evidence according to the design of the study. 9. Before the body of evidence can be evaluated, the team needs to evaluate the scientific merit of the studies and other evidence

sources found in the literature search. ANS: T

Before the body of evidence can be evaluated, the team needs to evaluate the scientific merit of the studies and other evidence sources found in the literature search. 10. A summary table consists of two items; (1) the overall strengths and (2) the overall weakness of the studies as a group.

ANS: F

A summary table consists of a number of content areas to identify commonalities and differences across studies regarding study findings, the types of patients to which findings can be applied. A well-done table also provides a synthesis of the overall strengths and weakness of the studies as a group. 11. Focus groups are a useful way to provide discussion about the evidence-based practice and to identify key areas that may be

potentially troublesome during the implementation phase. ANS: T

Focus groups are a useful way to provide discussion about the evidence-based practice and to identify key areas that may be potentially troublesome during the implementation phase.

Chapter 03: Developing Compelling Clinical Questions LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. A well-developed PICO question guides a focused search for scientific evidence about which of the following? a.

Assessing

Diagnosing

Treating

Providing patients with information about the prognosis for their specific health condition

All of the above

ANS: E

A well-developed PICO question guides a focused search for scientific evidence about assessing, diagnosing, treating, or providing patients with information about the prognosis for their specific health condition. 2. A nurse practitioner is reviewing current treatment modalities for patients with heart failure. To identify which proportion of the

population is living with the problem, which kind of study will most likely provide the best evidence? a.

Incidence

Prevalence

Etiology

Screening

ANS: B

Prevalence determines what proportion of the population is currently living with the problem. Incidence indicates what proportion of the population is newly diagnosed with the problem every year. Etiology refers to the cause of the problem and screening will detect the problem early before symptoms make a difference in the individuals’ health. 3. A team of health care providers practicing in a women’s health clinic question how accurate the urine pregnancy test routinely used

in the office is for detecting pregnancy. Which type of study should the team review to provide the best evidence? a.

Screening

Diagnosis

Therapy

Prevalence

ANS: B

Diagnosis determines how good the test is for detecting a problem. Screening will detect the problem early before symptoms make a difference in the individuals’ health. Therapy involves what should be done to treat the problem. Prevalence determines what proportion of the population is currently living with the problem. 4. Health care providers in a public health department are trying to determine the cause of increased numbers of people developing

acute kidney injury. Which type of study review will most likely provide the best evidence for the group investigating this problem? a.

Screening

Prognosis

Harm

Etiology

ANS: D

Etiology focuses on the cause of the problem. Screening will detect the problem early before symptoms make a difference in the individuals’ health. Prognosis relates to what is the most likely outcome for the problem and harm tries to detect if there will be any negative effects of the intervention. 5. The accuracy of a diagnosis is also referred to as a.

null hypothesis.

type II error.

sensitivity and specificity.

hypothesis.

ANS: C

Test sensitivity is the ability of a test to correctly identify those with the disease and test specificity is the ability of the test to correctly identify those without the disease. Null hypothesis is a statement of no difference or no relationship between and among the variables of a research design. Type II error is the decision to retain a false null hypothesis and hypothesis is defined as a supposition or proposed explanation made on the basis of limited evidence as a starting point for further investigation. 6. Which of the following is a component of the patient/population/problem step of the PICO process? a.

Diagnosis

Prognosis

Intervention

Placebo

ANS: A

Diagnosis, age, gender, ethnicity/race, and marital status are components of the patient/population/problem section of PICO. Prognosis is a component of the intervention or clinical issue of interest section of PICO. Intervention and placebo are components of the intervention or clinical issue of interest section of PICO.

7. Which of the following is not a component of the outcome step of the PICO process? a.

Alternative prognosis

Accuracy of diagnosis

Risk of disease or condition

Rate of occurrence of adverse outcome

ANS: A

Components of the outcome step of the PICO process include: risk of disease or condition; expected/predicted outcome expected from therapy/intervention; accuracy of diagnosis; and rate of occurrence of adverse outcome. 8. Which of the following is an example of a therapy/intervention PICO question format? a.

In patients who smoke a pack of cigarettes a day, does high blood pressure relative to coronary artery disease increase the risk for or influence of quality of life?

What is it like for female patients with morbid obesity to experience a vaginal delivery?

In adults with COPD, what is the effect of 24 hour a day oxygen therapy in comparison to 12 hour continuous oxygen therapy on oxygen saturation?

Is there an increase incidence of motor vechicle crashes among individuals who text while driving?

ANS: C

Response C is an example of therapy/response PICO question format. Response A is an example of prognosis PICO question format. Response B is an example of meaning or process PICO question format. Response D is an example of causation/harm/etiology PICO question format.

TRUE/FALSE

1. Research evidence, clinical judgment, and patient preferences are used to validate, develop, or revise best practices.

ANS: T

Research evidence, clinical judgment, and patient preferences are used to validate, develop, or revise best practices. 2. PICO is a tool to evaluate EBP.

ANS: F

PICO is a tool to help you formulate the clinical question. Components of PICO include: population, problem; intervention; comparison; outcomes. 3. Screening studies provide the best possible evidence for clinical questions trying to determine how a problem can be prevented.

ANS: F

Prevention studies provide the best possible evidence for determining how a problem can be prevented. Screening will detect the problem early before symptoms make a difference in the individuals’ health. 4. Incidence refers to the proportion of the population that is newly diagnosed with a particular problem each year.

ANS: T

Incidence refers to the proportion of the population that is newly diagnosed with a particular problem each year. 5. Prevalence refers to what proportion of the population is currently living with the problem.

ANS: T

Prevalence refers to what proportion of the population is currently living with the problem.

Chapter 04: Search and Critical Appraisal of the Literature LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. A nurse researcher who is searching the literature identifies which of the following as an example of a primary source? a.

Unpublished “gray” literature

Clinical practice guidelines

Critiqued abstracts

Point-of-care (POC) tools

ANS: A

Examples of primary sources include: peer-reviewed research studies, systematic reviews that are meta-analyses, non-peer reviewed articles (editorials), public health reports and news, clinical trials in progress, statistical data sets, websites, social media postings, personal communications, expert opinions and unpublished “gray” literature. Examples of secondary sources include: textbooks, review articles that are narrative reviews, integrative reviews, systematic reviews, pre-appraised studies, critiqued abstracts, evidence summaries and synthesis (POC tools), and clinical practice guidelines. 2. A nurse researcher who has gained competence with search tools to search for and retrieve research evidence utilizing multiple

desktop or handheld applications, appraisal tools, and citation management tools would be best described as having acquired a.

search competence.

digital functionality.

critical thinking.

metaliteracy.

ANS: D

Metaliteracy is described as the ability to manage digitized sources, leveraging search tool interfaces, and utilizing the full functionality of multiple platforms. Metaliteracy includes the ongoing adaption to emerging technologies and an understanding of the critical thinking and reflection required to engage in these spaces. 3. An experienced nurse researcher is mentoring a nurse who is new to the process of discovering evidence for a clinical question.

The experienced nurse cautions the mentee to avoid search bias which can be best defined as a.

reviewing literature for a predetermined time period.

skewed or insufficient retrieval of literature that results from a careless or incomplete search strategy or selection of the wrong database.

limiting the literature search to one particular discipline.

review of literature that was only conducted in the United States.

ANS: B

Search bias is best defined as the skewed or insufficient retrieval of literature that results from a careless or incomplete search strategy or selection of the wrong data base. 4. One of the advantages of using a search engine such as Google Scholar as an instructive first step for strategic exploration is? a.

Manageable numbers of hits will most often result.

Hits are identified indicating if they are freely available or located behind a paywall.

Identification of evidence that is highly cited in the literature

Each hit is identified as scholarship and ‘user-generated” content.

ANS: C

A pitfall of broad web scales tools such as Google Scholar often retrieve an overwhelming and unmanageable number of hits. The list generated from search engines such as Google Scholar often mask what is freely available and what is behind a paywall. The results are also often vast and unfiltered. 5. A nurse researcher who is seeking evidence for the knowledge-trigger question “Does use of music therapy as an intervention

decrease anxiety in patients awaiting surgery in the pre-operative holding area?” should use which data base to most likely obtain the most useful results? a.

Google Scholar

Google

Yahoo

Cumulative Index to Nursing and Allied Health Literature

ANS: D

Pub/Medline and Cumulative Index to Nursing and Allied Health (CINAHL) are both biographical indexes of research for biomedicine, nursing, and allied health. Results from the other options will most likely provide an unwieldy number of hits increasing the potential for not selecting the most relevant hits. 6. Which core database consists of journals from more than 90 countries? a.

Embase

Scopus

Web of Science

ProQuest Central

ANS: A

Embase is a biomedical and pharmaceutical database that indexes journals from more than 90 countries on a number of topic areas. Scopus is a multidisciplinary index of peer-reviewed journals and conference covering science, technology, medicine, social sciences, and arts and humanities. Web of Sciences is a multidisciplinary research platform with linked content citations metrics from multiple sources and ProQuest Central is a large multidisciplinary database that includes scholarly sources as well as newspapers and popular periodicals.

7. When reviewing findings as the nurse researcher searches for evidence to investigate a clinical question, the nurse identifies which

type of study as having the most merit? a.

Randomized controlled trials

Cohort studies

Systematic reviews

Case controlled studies

ANS: C

The evidence for health care interventions is hierarchical. The highest quality of evidence is systematic reviews followed by critically appraised topics, critically appraised individual articles, randomized controlled trials, cohort studies, case controlled studies, and background information/expert opinion. 8. A member of the team investigating a clinical question asks the group what a white paper is. The best description of a white paper

includes which one of the following? A white paper a.

is an example of gray literature; fugitive, ephemeral, invisible, unpublished, unevaluated, and not peer-reviewed.

can be described as agreed upon expert opinion on a particular topic.

a consensus statement from a national group of practitioners.

the last step of a clinical practice review prior to being designated best practice status.

ANS: A

A white paper is an example of gray literature; fugitive, ephemeral, invisible, unpublished, unevaluated, and not peer-reviewed. The other statements are not true. 9. Which of the following is a resource specific for nursing research? a.

Florence Nightingale British Nursing e-Repository

National League for Nursing Database

Virginia Henderson Global Nursing e-Repository

American Nurses for Research

ANS: C

A resource specific for nursing research is the Virginia Henderson Global Nursing e-Repository. This source includes information that goes beyond published research including gray literature and clinical trial in progress. 10. Which of the following statements regarding point-of-care tools is true? a.

UptoDate is an example of a point-of-care tool.

Cautious use of point-of-care tools is recommended as they are considered to be low quality evidence.

Information provided by point-of-care tools is for clinicians only.

Point-of-care tools are exclusively used by researchers.

ANS: A

UptoDate, Nursing Reference Center Plus, Clinical Key, and McMaster University’s Nursing+ are examples of point-of-care tools. Point-of-care tools are summarized high quality evidence, pre-appraised synopses, case sheets, and patient-level handouts that can be used at the bedside by multiple clinicians. 11. A researcher is initiating location of evidence to find all of the relevant studies published and unpublished on a topic or question. It

would be best for the researcher to locate information from which type of research method? a.

Randomized controlled trial

Meta-analysis

Case study analysis

Systematic review

ANS: D

A systematic review also referred to as a review is a type of research method whereby researchers find all of the relevant studies, published and unpublished, on a topic or question and present a state of the science conclusion in the form of an evidence summary. A meta-analysis is a type of systematic review that takes the results of multiple studies in a specific area, quantitatively analyzes the findings as an aggregate, and presents a quantitative conclusion about the strength of the evidence provided by the group of studies. Recommendations about the applicability of the findings may be made. Results from a randomized controlled trial and case

study analysis provided information from the particular study only. 12. A team of providers are seeking information regarding an innovative method of patient teaching. Which type of study would most

likely provide the best information regarding applicability of the innovative patient teaching method to the patient population? a.

Meta-analysis

Evidence summary

Standard of care

Qualitative data

ANS: A

Meta-analysis is a type of systematic review that takes the results of multiple studies in a specific area, quantitatively analyzes the findings as an aggregate, and presents a quantitative conclusion about the strength of the evidence provided by the group of studies. They may also make recommendations about the applicability of the findings. Evidence summary is a short summary of available evidence that may provide pre-synthesized data as well as recommendations for research and clinical practice. Standard of care is defined as that of what a reasonable and prudent nurse would do when caring for a same or similar patient in the same or similar circumstances and qualitative data is defined as measures of “types” and may be represented by a name, symbol, or a number code.

13. A group of researchers have developed the clinical question, “What is the evidence for using meditation as an intervention to

decrease patients’ postoperative pain?” Using the PICO framework, what is the intervention? a.

Meditation

Postoperative patients

Music therapy

Lower pain level

ANS: A

The intervention is meditation. The patient population is postoperative patients, the comparison is music therapy, and the outcome is lower pain level. 14. The process of expanding the search from the most relevant studies by following the reference lists backward and following articles

that cite an article following publication is referred to as a.

automatic explosion.

breadcrumbs.

snowballing.

false hits.

ANS: C

Snowballing (following the reference lists backward and following articles that cite an article following publication) provides the opportunity to expand the search from the most relevant studies to explore links to related records or similar articles. Breadcrumbs is the term used to describe the descriptive metadata seen in relevant citations or located in online database thesauri which define and disambiguate terms as well as situate terms hierarchically providing links to similar articles. Automatic explosion is described as use of metadata from search engines such as PubMed indicating broader categories to include. False hits are described as hits or findings that may not provide the particular information sought. 15. Which of the following is a citation management tool? a.

PRISMA

Zotero

AGREE

PlumX Metrics

ANS: B

Zotero is a citation management tool. PRISMA Diagram Generator is a systematic review tool. AGREE Enterprise Website is an appraisal tool, and PlumX Metrics is a scholarly metrics tool.

TRUE/FALSE

1. A first step toward conducting a literature search is use of the PICO format to ASK a clinical question.

ANS: T

Use of the PICO format to ASK a clinical question identifying the patient, problem, or population of interest and the proposed intervention is a first step toward conduction a literature search. 2. Primary sources are derived from or are interpretations of secondary sources and secondary sources are interpretations of researcher

opinions. ANS: F

Primary sources are original evidence and secondary resources are derived from or are interpretations of primary sources. 3. The first three steps incorporated to evaluate the strength of a research study include ASK, GATHER, ASSESS/APPRAISE.

ANS: T

The first three steps to evaluate the strength of the research evidence are ASK, GATHER, ASSESS/APPRAISE. 4. Web scale tools have little functionality for filtering results.

ANS: T

When starting the process of discovering evidence for a clinical question, the researcher needs to be aware that when using web

scale tools, there is little functionality for filtering results. 5. Gray literature is peer-reviewed information on a specific topic accepted as state of the art science?

ANS: F

Gray literature is fugitive, ephemeral, invisible, or unpublished, is unevaluated, and not peer-reviewed. 6. A scoping search identifies the existing evidence or a gap in research and informs the focus for developing a refined PICO

question. ANS: T

A scoping search identifies the existing evidence or a gap in research and informs the focus for developing a refined PICO question. 7. A meta-analysis is a systematic review, not all systematic reviews are meta-analysis.

ANS: T

A meta-analysis is a systematic review, however not all systematic reviews are meta-analysis. 8. Discovery of research evidence is a finite process of inquiry.

ANS: F

Discovery of research evidence is an iterative or a ceaseless process of inquiry.

9. Controlled vocabulary is an online thesaurus of terms that disambiguate and facilitate more precise retrieval using search terms.

ANS: T

Citations are described as “tagged” with metadata drawn from a controlled vocabulary, which is an online thesaurus of terms that disambiguate and facilitate more precise retrieval using search terms. 10. Database search interfaces vary, but all rely on the use of Boolean connectors ALSO and EITHER.

ANS: F

Database search interfaces vary, but all rely on the use of Boolean connectors AND and OR.

Chapter 05: Principles of Assessing Research Quality LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. A group of researchers are working on a practice change in their facility. They have developed a PICO question and completed a

search of the literature. The next phase of the practice change involves? Obtain organizational approval to implement the change

Dissemination of the findings to stakeholders

Critically appraising the identified studies

Plan implementation of the practice change

ANS: C

The first step of the EBP process is to develop a PICO question and search the literature. The next phase of a practice change involves critically appraising the identified studies. Each study needs to be evaluated to assess its overall scientific quality, including the design, sample type and size, measurement instruments, data collection, and data analysis methods. The group should also evaluate the studies as a collective group by synthesizing the overall strengths, quality, and consistency of the evidence provided by the studied retrieved. 2. Measures the researcher uses to hold the conditions of the study consistent to minimize possible bias in selection of subjects,

randomization, or assignment to experimental and control group as well as error in the measurement of the dependent variables is referred to as a.

external validity.

control.

internal validity.

homogeneity.

ANS: B

Control is defined as the measures that the researcher uses to hold the conditions of the study consistent thereby minimizing possible bias in selection of subjects, randomization, or assignment to experimental and control groups and error in the measurement of the dependent variables. External validity is the degree to which findings can be generalized to other populations or environments. Internal validity is the degree to which one can infer that the experimental treatment, rather than another condition or variable resulted in the outcome or observed effect. Homogeneity is defined as the similarity of conditions. 3. When reviewing a study, it is important for the researcher to assess the sample for a.

mortality.

generalizability.

selection bias.

homogeneity.

ANS: D

Homogeneity or similarity with respect to minimizing extraneous variables relevant to the particular study is important to maintain control. Mortality is the loss of subjects. Generalizability is the inference that the data are representative of a similar phenomenon in a different population and selection bias is an internal validity threat that arises when pretreatment differences between the experimental and control group are present. 4. A researcher is reviewing the data-collection area of a randomized controlled trial that asked the research question, “What is the

optimal length of a teaching program to promote adherence to an oral hygiene program in pre-school children?” The researcher notes that the intervention, data collection, and implementation maintained constancy throughout the study. The researcher is then able to determine that the study has a.

intervention fidelity.

control.

randomization.

reactivity. 1

ANS: A

Intervention fidelity is the constancy in the delivery of the intervention throughout the study meaning that environmental conditions, timing of data collection, data-collection instruments, and data-collection procedures used to collect data were the same for each subject. Control is a term used to state that measures the researcher used to hold the condition of the study consistent are present. Randomization is a sampling procedure in which each person has an equal chance of being selected to either the experimental or control group, and reactivity refers to distortion created when those who are being observed change their behavior because they know they are being observed. 5. Which of the following is true when describing interventional studies? a.

A control group is not used.

Manipulation of the dependent variable is used as a means of control.

The group the receives the program, treatment, or interventian is called.

Bias is not a consideration.

ANS: C

Intervention studies are used to test whether a treatment or intervention effects patient outcomes. The group the receives the program, treatment, or intervention in an interventional study is the experimental group and the other group is known as the control group. In studies that test an intervention, manipulation of the independent variable is used as a means of control. Bias is always a consideration in research design.

6. In a study that aims to test an intervention to improve renal failure patients adherence to a medication trial, antidepressant

medication given to some patients during the medication trial would be considered to be all of the following except a.

intervening variable.

extraneous variable.

mediating variable.

control variable.

ANS: D

An extraneous, mediating, or intervening variable is one that interferes with interpretation of the dependent variable or outcome. There is no control variable. 7. Internal validity assesses for which of the following? a.

If the data was collected in a consistent manner

If the change in the dependent variable or study outcome was related to the independent variable

If the sample size was representative of all studied

If the study methods were uniform

ANS: B

Internal validity assesses if the change in the dependent variable or study outcome was related to the independent variable. The degree to which researchers maintained constancy in data collection is known as fidelity; homogeneity or similarity. Maintaining constancy minimizes extraneous variables relevant to the study. Intervention fidelity refers to the uniformity of the study methods. 8. When assessing the evidence of a study, the researcher notes that there is a threat to internal validity of the study. The research

should consider all of the following except a.

determine that the study should not be considered as relevant.

take the threats to internal validity into consideration.

review threats to internal validity and weigh the total evidence of the study for statistical meaningfulness.

weight the total evidence of the study for clinical meaningfulness.

ANS: A

It is quite difficult at times to avoid threats to internal validity. The study should not be considered useless. Threats to internal validity should be considered weighing the total evidence of a study for its statistical meaningfulness as well as its clinical meaningfulness. 9. Which of the following is the best description of external validly? a.

The degree to which one can infer that the experimental treatment rather than another condition or variable resulted in the outcome or observed effect

Assessment that the intervention the subject performs is completed as intended

Similarity of conditions among all participants was present.

The degree to which findings can be generalized to other populations or environments

ANS: D

External validity is the degree to which findings can be generalized to other populations or environments. Internal validity is the degree to which one can infer that the experimental treatment rather than another condition or variable resulted in the outcome or observed effect. Enactment is assessment that the intervention the subject performs is completed as intended. Homogeneity refers to the similarity of conditions. 10. A group of health care providers studied the impact of three different respite programs for caregivers responsible for individuals

with advanced Alzheimer’s disease. The caregivers were given detailed information about the study and what the findings were from previous studies. When reviewing results of the study, the researchers noted that all of the caregivers had a decrease in perceived stress and increased satisfaction. It is possible that the caregivers may have experienced a.

reactivity.

testing.

maturation. 3

homogeneity.

ANS: A

Reactivity or the Hawthorne effect is distortion created when those who are being observed change their behavior because they know they are being observed. Testing refers to the effect of taking a pretest on a posttest. Maturation is developmental, biological, physiological, or psychological processes within an individual as a function of time and is external to a study’s events. Homogeneity refers to the similarity of conditions of a study. 11. When reviewing a study in which a pretest was administered before an intervention was performed, which of the following terms is

used to describe the effect on generalizability of the findings due to the pretest? a.

Reactive effects

Selection effect

Measurement effect

Selection bias effect

ANS: C

When a study is conducted and a pretest is given, it may “prime” the subjects and affect the ability to generalize to other situations and is referred to as measurement effect. Reactive effects is the subject’s response to being studied, selection effect occurs when the researcher cannot attain the ideal sample population and selection bias occurs is an internal validity threat that arises when pretreatment differences between the experimental and control group are present.

12. To avoid selection bias, it would be best for the researcher to a.

maintain constancy.

assure homogeneity.

include randomization of groups.

limit maturation.

ANS: C

Randomization of groups will avoid selection bias which can result if precautions are not taken when subjects are chosen. Constancy is referred to as sameness in methods and procedures of data collection. Homogeneity is similarity of conditions during the study. Maturation can occur in studies that test an intervention or variable over time and refer to the developmental, biological, physiological, or psychological processes within an individual as a function of time and are external to a study’s events differences between the two testing periods rather than the experimental treatment. 13. A pilot study can be best described as a.

making sure all of the conditions in the study are the same.

a small study conducted as a prelude to a larger scale study.

changes in the measurement of a variable that may account for changes in the obtained measurement.

degree of control or uniformity of the study methods.

ANS: B

A pilot study is a small study conducted as a prelude to a larger scale study. Homogeneity is assurance of similarity of conditions in the study. Instrumentation refers to changes in the measurement of a variable that may account for changes in the obtained measurement. Fidelity refers to the degree of control or uniformity of the study methods. 14. Which of the following is not a component of intervention fidelity? a.

Enactment

Training

Delivery

Internal validity

ANS: D

Elements of intervention fidelity include: design, training, delivery, receipt, and enactment. Internal validity assesses if the change in the dependent variable or study outcome was related to the independent variable.

TRUE/FALSE

1. The lack of manipulation of the independent variable of a study results in a weaker study.

ANS: F

The lack of manipulation of the independent variable does not mean a weaker study. 2. Threats to internal validity are assessed in intervention studies and are not considered in quantitative studies.

ANS: F

Threats to internal validity are mainly assessed in intervention studies but can also compromise outcomes of all quantitative studies. 3. When assessing the evidence, more than one threat can be found in a study design.

ANS: T

Depending on the study design, more than one threat can be found in a study. 4. Finding a threat to internal validity in a study invalidates the study’s results.

ANS: F

Finding a threat to internal validity in a study does not invalidate a study’s results but it should be acknowledged in the study’s “Results” or “Discussion” or “Limitations” section. 5

5. Problems of internal validity are generally easier to control compared to problems with external validity.

ANS: T

Problems of internal validity are generally considered easier to control, however external validity is usually more difficult to control because it means that the researcher is assuming that other populations are similar to the one being tested. As more controls are designed into a study, internal validity improves, but generalizability is likely to decline. 6. Evaluation is the synthesis of the overall strengths, quality, and consistency of the evidence provided by the studies retrieved.

ANS: T

Evaluation occurs by synthesizing the overall strengths, quality, and consistency of the evidence provided by the studies retrieved. 7. External validity is the degree to which findings can be generalized to other populations or environments.

ANS: T

External validity is the degree to which findings can be generalized to other populations or environments. 8. Internal validity refers to the consistency among and between the groups being studied.

ANS: F

Internal validity is the degree to which one can infer that the intervention, rather than another condition or variable, resulted in the outcome or observed effects.

Chapter 06: Intervention Studies LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. Which of the following terms is used to describe the process of protecting the randomization process to make sure the group

assignment is not readily known by anyone before the subject is assigned to a group? a.

Concealment

Blind

Control

Intent-to-treat analysis

ANS: A

The process of protecting the randomization process to make sure the group assignment is not readily known by anyone before the subject is assigned to a group is known as concealment. Blind, blinded, or blinding is the process of making unknown what the subject is receiving in the study. Control is the arm of a randomized trial in which participants receive the standard treatment or possibly a placebo, and intent-to-treat analysis is the statistical process of analyzing data according to randomized groups exactly as it exists upon randomization. 2. Which term is used to describe a trial that is statistically powered and designed to test an intervention under well-controlled

conditions. a.

Open label

Effectiveness trial

Feasibility study

Efficacy trial

ANS: D

An efficacy trial is a trial that is statistically powered and designed to test an intervention under well-controlled conditions. An effectiveness trial is a trial that is designed to test an intervention under “real-world” conditions. A feasibility study is designed to examine if the planned intervention is worth testing in a larger full-scale. It is also used as a trial to identify modifications needed to the intervention, methods, or design. Open label is a type of trial in which both the researcher and the study subjects know what they are receiving. 3. Which of the following statements about intervention studies does the nurse researcher identify as not being true? a.

Intervention studies are often called randomized controlled (clinical) trials.

Intervention studies are the weakest design type for an individual study.

Intervention studies are located at level I on the evidence hierarchy.

Intervention studies are the most appropriate type of design to test prognosis.

ANS: A

Rationale intervention studies are often called randomized controlled (clinical) trials. They are the strongest design type for individual studies and are located at level II on the evidence hierarchy. RCTs are the most appropriate type of design to answer questions about the effectiveness and efficacy of interventions focused on testing cause and effect relationships. 4. When describing quasi-experimental design to a research team, which of the following statements should the team leader include? a.

Quasi-experimental designs are a type of randomized controlled trial.

Quasi-experimental groups include a comparison group and randomization.

Quasi-experimental designs are located at level III on the evidence hierarchy.

Quasi-experimental designs have a lower risk of bias compared to randomized controlled trials.

ANS: C

Quasi-experimental designs are located at level III on the evidence hierarchy. Quasi-experimental designs lack either a comparison group or randomization and have a higher risk of bias. Quasi-experimental designs are different from randomized controlled trials. 5. Which one of the following statements about efficacy is true? 1

Efficacy refers to how well the intervention perfroms under ideal and controlled conditions like a research study.

Efficacy refers to an intervention’s performance under “real-world” conditions

Effectiveness must be established first before an efficacy trial is undertaken

Efficacy is established by implementing a qualitative study

ANS: A

Efficacy refers to how well the intervention performs under ideal and controlled conditions like a research study. Efficacy has be be established first before an effectiveness trial is undertaken. Efficacy is established by implementing an RCT. Effectiveness refers to an intervention’s performance under “real-world” conditions, sometimes called a pragmatic trial.

6. A clinical leadership team is planning to test an intervention they developed. Which of the following is the most appropriate

research design for the group to use? a.

Quasi-experimental design

Randomized controlled trials

After-only design

Pilot study

ANS: B

Randomized controlled trials, commonly called intervention studies use an experimental design and are the gold standard for testing an intervention. Quasi-experimental intervention studies test for change through manipulation of the independent variable; however they lack one of the three key properties of an experimental design, typically randomization, or presence of a control group. The after-only design is less frequently used and is a weaker design composed of two randomly assigned groups and unlike the classic experimental design, neither group is pretested. A pilot study is defined as a small sample study conducted as a prelude to a larger sale study to establish if sufficient scientific evidence exists to justify subsequent more extensive research while providing more experience for the research team. 7. When designing an intervention study using an experimental design, which of the following is not an essential feature to be

included in the design? a.

Control

Centralized data storage

Randomization

Manipulation

ANS: B

A randomized controlled trial is characterized by control, randomization, and manipulation. Although data storage is important, it is not considered to be one of the three essential features. 8. Which of the following would be the most effective design to use when testing a post-cesarean section delivery pain management

intervention? a.

Crossover design

Solomon four-group design

Randomized controlled trial

After-only design

ANS: D

The after-only design is used less frequently and is a weaker design composed of two randomly assigned groups, but unlike the classic experimental design, neither group is pretested. This design is useful when pretesting of outcomes is not possible such as when testing the effectiveness of a post-cesarean section delivery pain management intervention. A crossover design is considered a repeated measures design in which subjects serve as their own controls. Solomon four-group design consists of two experimental and two control groups. Two groups are identical to those used in the classic experimental design plus two additional groups, an experimental after-group and a control after-group. Solomon four-group design results in two groups that receive only a posttest rather than a pre- and posttest. This design provides an opportunity to minimize testing bias that may have occurred because of exposure to the pretest. A randomized control trial requires control, randomization, and manipulation of variables. 9. Which of the following designs would be most effective for a research team to use when determining which key ingredients in a

bundled intervention make a difference over time using a factorial design to pull apart each component and test then in varying combinations? a.

Pragmatic trial design

SMART design

Intervention study

MOST design

ANS: D

Multiphase optimization strategy (MOST) is a proposed alternative approach to RCTs. MOST uses a factorial design to pull apart each component and test them in varying combinations to extract which key ingredients in a bundled intervention make a difference over time. Sequential multiple assignment randomized trial (SMART) allows tailored components based on patient responses taking into account individual patient responses, adherence to treatment and personal preferences to be used in tailoring 3

the intervention. Guidelines for these individualized sequences of treatment are known as dynamic treatment regimens (DTRs). Pragmatic trial designs evaluate the effectiveness of an intervention previously tested for efficacy in traditional experimental designs. The focus is on whether the intervention is doable and effective in the real-world clinical setting compared to other accepted clinical practice treatments. An intervention study is also known as a therapy study or randomized controlled trial. 10. Which of the following statements about quasi-experimental design is not true? a.

Quasi-experimental designs lack all of the three key properties of an experimental design.

The basic problem with quasi-experimental designs is weakened confidence in making causal assertions that the results occurred because of the intervention.

Quasi-experimental intervention studies test for change through manipulation of the independent variable.

Threats to internal validity such as selection effect, testing, and mortality are common with quasi-experimental design.

ANS: A

Quasi-experimental designs lack one of the three key properties of an experimental design usually randomization or presence of a control group. Threats to internal validity such as selection effect, testing, and mortality are common with quasi-experimental design. Quasi-experimental interventions test for change through manipulation of the independent variable. The basic problem with quasi-experimental designs is weakened confidence in making causal assertions that the results occurred because of the intervention.

11. Benefits of keeping a sharp discerning eye out for potential threats to both internal and external validity of intervention studies help

the reader determine all of the following except: a.

Are the results of the study legitimate?

Do the interventions do no harm?

Will the intervention be easy to implement?

Are the conclusions in the publication rigorous?

ANS: C

Keeping a sharp discerning eye out for potential threats to both internal and external validity helps the reader determine if the results of the studies under consideration for incorporation into evidence-based practice are; legitimate, do no harm, and that the conclusions in the publication are rigorous, efficacious, and effective. Ease of implementation into clinical practice is not a consideration. 12. Which of the following should the reader assess when thinking about critically appraising intervention fidelity? a.

Blinding

Use of an Intervention Manual

Power analysis

Power calculation

ANS: B

The following should be assessed when thinking about critically appraising intervention fidelity; use of an Intervention Manual, were all research personnel trained on the careful execution of the intervention, the consistency with which the researchers executed the intervention, and measurement of adherence to the protocol. Blinding, also called masking, is the process of concealing from the researchers, recruiters, interventionists, subjects, and/or data collectors what treatment the subjects are receiving in the study. Power analysis is calculated to reduce the probability of making a type II error. A power calculation is used to determine the number of participants needed to detect a small, medium, or large treatment effect as well as if there is a difference between the intervention and control condition at a predetermined level of significance. 13. A CONSORT Diagram is best defined as an analysis of a.

content validity.

construct validity.

treatment fidelity.

If the number of participants originally enrolled in the trial complete the study.

ANS: D

A CONSORT Diagram evaluates whether the number of participants originally enrolled in the trial completed the study. Content validity is the most common type of validity seen resented in research articles. Construct validity is more often referred to in citations from original psychometric studies and treatment fidelity refers to processes used to make sure that the research intervention, and all related activities, were delivered exactly as planned to ensure that the treatment effect found or not found was due to the intervention, and not to alternations in execution of the study.

TRUE/FALSE

1. CONSORT is the abbreviation used for the consolidated standards of reporting trials which outlines the standards for reporting all

aspects of randomized clinical trials. ANS: T

CONSORT is the abbreviation used for the consolidated standards of reporting trials which outlines the standards for reporting all aspects of randomized clinical trials. 2. Clinical leaders can assume that the evidence provided by intervention studies is always strong enough to be translated into practice

by automatically applying the findings to a patient care problem. ANS: F

Clinical leaders must not assume that the evidence provided by intervention studies is always strong enough to be translated into practice by automatically applying the findings to a patient care problem. Clinicians must evaluate and critically appraise the 5

strength, quality, and consistency of evidence provided by intervention studies before making a decision about applying it to practice. 3. Randomized controlled trials are the gold standard for testing an intervention.

ANS: T

Randomized controlled trials use an experimental design and are the gold standard for testing an intervention. 4. Randomized controlled trials provide robust external validity, which often reduces internal validity.

ANS: F

Randomized controlled trials are the standard design for testing interventions. RCTs provide robust internal validity, which often reduces external validity. 5. Quasi-experimental designs provide level II evidence and have lower risks of bias.

ANS: F

Quasi-experimental designs provide level III evidence and have a higher risk of bias because randomization is absent. Randomized clinical trials provide level II evidence and have a lower risk of bias. 6. A pilot study is often called a “parent study.”

ANS: T

A pilot study is defined as a small sample study conducted as a prelude to a larger scale study and is often called the “parent study.”

7. It is unclear what level of evidence is produced by a pilot or feasibility study.

ANS: T

The reader should be cautious when reviewing published results of pilot and feasibility studies because the evidence they produce is only preliminary and applicable to a future full-scale trial. 8. Researchers conducting randomized controlled trials are interested in determining whether the randomly assigned intervention and

control groups are different after the introduction of the experimental treatment and how large the treatment effect is. ANS: T

Researchers conducting randomized controlled trials are interested in determining whether the randomly assigned intervention and control groups are different after the introduction of the experimental treatment and how large the treatment effect is. 9. Intervention studies are considered to provide the strongest research evidence to make causal assertions that inform clinical

decision making about applicability of research findings to clinical practice. ANS: T

Intervention studies are considered to provide the strongest research evidence to make causal assertions that inform clinical decision making teams about applicability of research findings to clinical practice. 10. Threats to internal and external validity are the benchmark criteria to use in critiquing whether a study’s outcomes were truly the

cause of the effect of the intervention on the dependent variable. ANS: T

Threats to internal and external validity are the benchmark criteria to use in critiquing whether a study’s outcomes were truly the cause of the effect of the intervention on the dependent variable.

Chapter 07: Observational Studies LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. Which of the following statements about observational studies is true? Observational studies a.

are used when researchers intend to explore people as they naturally occur.

determine best practice guidelines.

manipulate variables.

do not incorporate randomization.

ANS: A

Observational studies are used when researchers’ intent to explore events, people, or situations as they naturally occur; or test relationships and differences among variables. Observational studies construct a picture of variables at one point or over a period of time and the variables are not manipulated or randomized. 2. All of the following are major types of observational studies except a.

cross-sectional.

survey.

randomized control trials.

cohort.

ANS: C

The major types of observational studies are: cohort, case-control, cross-sectional, and survey. 3. Observational studies provide which level of evidence? a.

Level I

Level II

Level III

Level IV

ANS: D

Observational studies provide level IV evidence. 4. All of the following statements about observational studies are true except: a.

The independent variable is not manipulated.

The independent variable is observed.

The independent variable is measured qualitatively.

Observational studies can use data from large data sets.

ANS: C

In observational studies the independent variable is not manipulated, it is observed and measured quantitatively. Observational studies can use data from large data sets or collect data directly from subjects. 5. Cohort studies are also known as all of the following except: a.

cross sectional.

longitudinal.

repeated measure.

retrospective or prospective

ANS: A

Cohort studies are also known as longitudinal, retrospective, prospective, and repeated measure. 6. Which of the statements about data for cohort studies is true? a.

Data is collected at multiple time points.

Subjects are randomized.

Subjects are chosen based by convenience sampling. 1

Exposure is controlled.

ANS: A

Data for cohort studies are collected at multiple time points. Subjects are not randomized in cohort studies. Subjects are chosen based on inclusion criteria. Exposure is not controlled in cohort studies. 7.

Which type of study is designed to assess the association between an exposure (independent variable) and an outcome (dependent variable)?

retrospective study

longitudinal study

cross sectional study

case control study

ANS: D

A case control study is designed to assess the association between an exposure (independent variable) and an outcome (dependent variable).A retrospective study begins with an outcome (dependent variable) and examines its relationship to another variable (independent variable) which preceded it. A longitudinal study is also known as a cohort, repeated measures or prospective study follow individuals who are alike but not identical over a period of time. A cross sectional study is designed to assess data at one point in time.

8. All of the following can be used to describe case series designs except: a.

A control group is used.

There is no comparison group.

The sample is one of convenience.

A consecutive of patients treated in a similar manner is used.

ANS: A

Case series designs are studies that collect data from a consecutive sample of patients treated in a similar manner without a control group or a comparison group. Only one group is included, there is no control group, and the sample is one of convenience. 9. Variables in surveys can be classified as all of the following except a.

opinions.

attitudes.

facts.

truths.

ANS: D

Variables in surveys can be classified as opinions, attitudes, or facts. 10. Surveys have all of the following advantages except: a.

Survey data can solely support a practice change.

Survey research information is surprisingly accurate.

If a sample is representative of the population a relatively small number of subjects can provide an accurate picture of the population.

A great deal of information can be obtained from a large population in a fairly economical manner.

ANS: A

Surveys can generate a great deal of information from a large population in a fairly economical manner. The survey research information can be surprisingly accurate. If the sample is representative of the population even a relatively small number of subjects can provide an accurate picture of the population. A practice change would not be based on survey data alone.

TRUE/FALSE

1. A cohort study is a study that collects data from a consecutive sample of patients treated in a similar manner without a control

group. ANS: F

A cohort study collects data from the same group of subjects. A case-control study is a study designed to collect data from a consecutive sample of patients treated in a similar manner without a control group. 2. A cross-sectional study is a study design that assesses data at one point in time.

ANS: T

A cross-sectional study is a study design that assesses data at one point in time. 3. A case-control study is designed to assess the association between an exposure and an outcome.

ANS: T

A case-control study is designed to assess the association between an exposure and an outcome. 4. Observational studies are a category of experimental studies.

ANS: F

Observational studies are a category of non-experimental studies. 5. A retrospective study is a study that begins with an outcome and examines its relationship to another variable which preceded it. 3

ANS: T

A retrospective study is a study that begins with an outcome and examines its relationship to another variable which preceded it. 6. Observational research is used when researchers need to assess exposure to a condition and when manipulation is not theoretically

or ethically possible, nor the aim of the study. ANS: T

Observational research is used when researchers which to assess exposure to a condition and when manipulation is not theoretically or ethically possible, nor the aim of the study. 7. Randomized controlled trials and quasi-experimental designs are the gold standards for answering PICO questions about the

efficacy or effectiveness of an intervention. ANS: T

Randomized controlled trials and quasi-experimental designs are the gold standards for answering PICO questions about the efficacy or effectiveness of an intervention. 8. Questions related to diagnosis, prognosis, harm, and etiology may best be answered by reviewing observational studies.

ANS: T

Questions related to diagnosis, prognosis, harm, and etiology may best be answered by reviewing observational studies.

9. Surveys relate one variable to another and determine causation.

ANS: F

Surveys related one variable to another and assess differences between variables. Surveys do not determine causation. 10. Survey studies can be classified as descriptive, exploratory, or comparative.

ANS: T

Survey studies can be classified as descriptive, exploratory, or comparative.

Chapter 08: Systematic Reviews and Clinical Practice Guidelines LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. The leader of the EBP team identifies systematic reviews of randomized controlled trials (RCTs) as providing which level of

evidence on the evidence hierarchy? a.

Level I

Level II

Level III

Level IV

ANS: A

Systematic reviews of randomized controlled trials (RCTs) are considered to provide level I evidence on the evidence hierarchy found at the top of the evidence pyramid. 2. A statistical approach to analyzing the data from a group of studies included in a systematic review is referred to as a(n) a.

integrative review.

narrative review.

meta-analysis.

scoping review.

ANS: C

A meta-analysis is a statistical approach to analyzing data from a group of studies included in a systematic review. A narrative review includes a review of the literature that includes studies that support an author’s perspective and provides a broad background discussion in a focused area of interest. A scoping review is a preliminary search and assessment of the potential size and scope of available research literature, including ongoing research. It aims to determine the value of undertaking a full systematic review. 3. Which type of review includes studies that support an author’s perspective to provide a broad background discussion in a focuased

area of intrest often not using a systematic approach to search for and appraise papers? a.

narrative review

realist review

scoping review

integrative review

ANS: A

A narrative review of the literature includes studies that support an author’s perspective and provides a boad background discussion in a focused area of interest. A systematic approach to searching for and appraising papers is often not used. A realist review provides explanatory anakysus aimed at discerning what works for whom, in what circumstances, and how. A scoping review is defined as a preliminary seach and assessment of the potential size and scope of available research literature, including ongoing research. It aims to determine the value of undertaking a full systematic review. 4. The first domain of structure and content of AGREE II is a.

scope and purpose.

stakeholder involvement.

rigor of development.

clarity of presentation.

ANS: A

The six domains of the structure and content of AGREE II include: Domain 1 Scope & Practice, Domain 2 Stakeholder Involvement, Domain 3 Rigor of Development, Domain 4 Clarity of Presentation, Domain 5 Applicability, and Domain 6 Editorial Independence. 5. An EBP group is preparing to complete a systematic review guided by a PICO question. To find the best available evidence, the

team should strive to locate which types of studies? 1

Quasi-experimental

Randomized controlled trials

Cohort studies

Case-control studies

ANS: B

Randomized controlled trials provide the best available evidence, however the reality of evidence-based practice is that these studies may not be available and that cohort and case-control studies may provide the strongest level of evidence and design type to answer the clinical question. The team should look for randomized controlled trials if they are available to provide the best evidence. 6. A leader of an EBP team planning to conduct a systematic review to help answer a PICO question impacting patient care across all

levels of care should do all of the following except: a.

Ensure all members of the team are from one discipline.

Appraise each study for validity and reliability.

Ask team members to independently perform data extraction.

Ask at least two members of the team to serve as independent judges to rate the quality of the studies using a standardized tool.

ANS: A

Systematic review should be completed by clinical teams representing multiple disciplines. Each study should be critically appraised for validity and reliability using standardized evaluation criteria and tools. More than one person on the team should evaluate the studies independently to complete data extraction and rate the quality of the studies using a standardized tool.

7. A clinician is a member of an EBP team completing a meta-analysis to answer a clinical question. The least important role of the

clinician is to a.

understand the meta-analysis.

think about the relevance of the findings to patients cared for.

understand statistics.

determine whether results are of sufficient quality and consistency to consider applying them to practice.

ANS: C

A meta-analysis is a complex and time consuming undertaking. The role of the clinician, educator, or administrator does not require an in-depth understanding of statistics. It is the role of the clinician, educator, or administrator to understand and interpret the findings of a meta-analysis to determine whether the results are of sufficient quality and consistency to consider applying them to practice and finally to think about their relevance for patient, student or staff resources, and setting. 8. An EBP team plans to perform a meta-analysis guided by their clinical question. The first step the team should follow to perform

the meta-analysis is a.

search only randomized controlled studies.

search by expert authors.

identify level of significance required in findings.

identify inclusion and exclusion criteria.

ANS: D

Identifying the inclusion/exclusion criteria is the first step. The other responses are not appropriate. 9. When reviewing results of the fail-safe number, the value is found to be large. The EBP team interprets this finding as a.

many studies would be needed to overturn the treatment effect results and one should be more confident about the reported findings.

the results of the meta-analysis are uncertain and easily could change if other studies were included.

publication bias exists.

studies with non-positive findings have not been published.

ANS: A

If the fail-safe number is large, many studies would be needed to overturn the treatment effects results and one would be more confident about the reported findings. If the fail-safe number is small, the results of the meta-analysis are uncertain and easily could change if other studies were included. 10. When reading a study, a member of the EBP team questions if outcomes assessors were appropriately blinded. This is an example

of which type of bias? a.

Selection bias

Performance and detection bias

Attrition bias

Reporting bias

ANS: C

Performance and detection bias refers to blinding of participants, providers, and outcomes assessors. Selection bias is determined by assessing the method of random assignment and process of allocation concealment. Attrition bias assesses how incomplete data were managed and reporting bias assesses whether all intended outcomes were reported. 11. A test of heterogeneity is completed during a meta-analysis and finds the null hypothesis is supported at the p < .05 level. The EBP

team interprets this as meaning. a.

There are multiple outliers.

The studies are too diverse or heterogeneous to be pooled legitimately and analyzed statistically as pooled sample in a meta-analysis and might conclude as non-quantitative systematic review.

The studies are considered similar and appropriate for a combined statistical analysis. 3

The effect size is too small.

ANS: C

When the null hypothesis is supported at the p < .05 level, the studies are considered similar and appropriate for a combined statistical analysis. If the null hypothesis is rejected, the studies are too diverse or heterogeneous to be pooled legitimately and analyzed statistically as pooled sample in a meta-analysis and might conclude as non-quantitative systematic review. Sensitivity analysis can be used to examine the effect of those studies that are outliers. 12. Which of the following statements about integrative review is incorrect? Integrative reviews a.

include critical appraisal of the literature in a specific area.

includes a statistical analysis.

are used to locate and evaluate studies.

are the broadest category of reviews and can include theoretical literature, research literature, or both.

ANS: B

Integrative reviews do not include statistical analysis due to the limitations of the study designs or the heterogeneity of the designs and samples. An integrative review is a critical appraisal of the literature in an area that does not include a statistical analysis due to the limitations of the study designs or the heterogeneity of the designs and samples. A systematic approach is used to locate and evaluate studies and samples. Integrative reviews are the broadest category of reviews and can include theoretical literature, research literature, or both.

13. The first step of critical appraisal of a meta-analysis or systematic review is: a.

Were the results similar from study to study?

Was a quality appraisal to evaluate the quality of the included studies completed by at least two independent judges using a standardized quality appraisal tool appropriate to the type of clinical question and design?

Was a high quality search performed?

Whether the study poses a clearly stated question?

ANS: D

Critical appraisal begins by assessing whether the study poses a clearly stated question. Other options are components of critical appraisal; however they are not the first. 14. Which statement about clinical practice guidelines is true? Clinical practice guidelines are a.

used exclusively in the United States.

based only on level I meta-analysis.

used at times to conduct a cost/benefit analysis.

always created to determine best practice for one health profession.

ANS: C

Clinical practice guidelines can be used to conduct a cost/benefit analysis. They are developed globally and can range from being scientifically rigorous based on level I meta-analysis evidence to level VII expert opinion. CPG are developed by organizations such as the US Preventive Services Task Force (USPTF), clinical specialty organizations, and providers. Clinical practice guidelines can involve interprofessional health care providers. 15. All but which of the following have been identified as a barrier that inhibits nurses from using clinical practice guidelines? a.

Lack of desire to participate in research

Lack of orientation and education

Amount of time it takes to implement CPG

Workload issues such as staffing

ANS: A

The top three barriers that inhibit nurses from using CPGs that have been identified include lack of orientation and education, amount of time it takes to implement them, and workload issues such as lack of staffing.

TRUE/FALSE

1. Clinical practice guidelines are systematically developed statements or recommendations that link research and practice and

provide an evidence-based practice guide for clinicians. ANS: T

Clinical practice guidelines are systematically developed statements or recommendations that link research and practice and provide an evidence-based practice guide for clinicians. 2. Effect size is a measure of the degree to which the null hypothesis is true, that is the treatment makes a significant difference.

ANS: F

Effect size is a measure of the degree to which the null hypothesis is false, that is the treatment makes a significant difference. 3. Fail-safe number uses odds ratio to calculate the number of studies reporting no treatment effect that would need to be included in

the analysis to reduce the pooled odds ratio to a nonsignificant value. ANS: T

Fail-safe number uses odds ratio to calculate the number of studies reporting no treatment effect that would need to be included in the analysis to reduce the pooled odds ratio to a nonsignificant value. 4. A Forest plot is a graph based on odds ratios that detects small study treatment effects. 5

ANS: F

A Forest plot is a visual reporting diagram of the individual study odds ratios (ORs) and confidence intervals (CIs) and the pooled OR and CI for the combined studies, illustrating the magnitude of the effect of the intervention. 5. A Funnel plot is a visual reporting diagram of the individual study odds ratios (ORs) and confidence intervals (CIs) and the pooled

OR and CI for the combined studies, illustrating the magnitude of the effect of the intervention. ANS: F

A Funnel plot is a graph based on odds ratios that detects small study treatment effects. 6. Integrative reviews include a critical appraisal of the literature in an area of interest that includes a statistical analysis.

ANS: F

Integrative review includes critical appraisal of the literature in an area of interest that does not include a statisti cal analysis due to the limitations of the study designs or the heterogeneity of the designs and samples. A systematic approach using explicit criteria is often used. 7. Meta-analysis is a quantitative epidemiological technique that is considered a subset of systematic review.

ANS: T

Meta-analysis is a quantitative epidemiological technique that is considered a subset of systematic review.

8. Rapid reviews use shorter time frames than for other evidence-based summaries providing rigorous and timely information to

respond to urgent clinical and public health-related questions. ANS: F

Rapid reviews use shorter time frames that for other evidence-based summaries providing a timely and valid review of evidence that sacrifice rigor. They are both review and assessment in response to urgent clinical and public health-related questions. 9. Quantitative synthesis by testing the effect of the intervention is what differentiates a meta-analysis from other types of systematic

reviews. ANS: T

Quantitative synthesis by testing the effect of the intervention is what differentiates a meta-analysis from other types of systematic reviews.

Chapter 09: Qualitative Studies LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. Which of the following best describes qualitative research? a.

A method to determine which nursing model is most effective

Comparison of two medications to determine which is most cost effective

Review of historical development of wound care

Description of health care needs and understanding of needs from the lived experience

ANS: D

Qualitative research methodologies provide a relationship between what patients and health care teams aspire in terms of improving health care services. Using qualitative methodologies, researchers work to operationalize theoretical explanations of life experience derived from actual patient experience. Options A and B require use of a quantitative methodology and option C is termed historical research. 2. A team of health care providers seek to understand opioid addicts’ lived experiecne while participating in a methadone treatment

program and opiate overdose rates. Which of the following will most likely be included in the research methodology? a.

Comparison of Methadone and Suboxone

Full exploration and description of the complexities of opioid addiction and its meaning to patients

Effectiveness of individual patient counseling versus group counseling

Inclusion of family members for all patient encounters throughout the program

ANS: B

Qualitative research explores and describes more fully the complexities of opioid addiction and their meaning to patients. The approach seeks to understand what is happening and occurring for the patient and the family as it is lived. Different qualitative research approaches can explore the meaning of illness from the lived experience of the individual living with acute or chronic illness. The other options would most likely be included in quantitative research methodologies. 3. A nurse manager leading a team of providers understands that prior to development a quantitative study to determine complication

rates of patients who have received a trans-aortic valve replacement (TAVR) it is most important for the group to a.

determine the data collection process.

identify statistical programs to run data.

develop the informed consent.

agree upon a theoretical basis for the study.

ANS: D

The basis for quantitative research methods is a theoretical basis to develop the study. The other options are included in the process, but are not the basis for quantitative study design. 4. Which of the following statements regarding qualitative research methods is true? a.

The sample size is large.

Randomized controlled sampling is most often used.

The common data collection method is interview with verbatim transcription of exactly what the participants have said.

A predetermined time for discussion between the researcher and participant is followed for all interviews.

ANS: C

The common data collection method is interview with verbatim transcription of exactly what the participants have said. The sample size in qualitative research is small. Purposive sampling is used to provide a homogenous group that reflects the population being studied. Time the researcher spends with the participants is not predetermined. When no new data emerges, often called saturation, data collection ends. 1

5. A health care team seeks to understand the lived experience of patients on left-ventricular assist device (LVAD) awaiting heart

transplant. Which approach to qualitative research will this team most likely use? a.

Ethnography

Phenomenology

Grounded theory

Meta-synthesis

ANS: B

Phenomenology is a science whose purpose is to describe a particular phenomenon, or the appearance of things, as lived experience. Lived experience is critical for the understanding of phenomenological reflection, meaning analysis, and insights. Ethnography is associated with anthropology, the work of describing culture and the people of a particular culture. Grounded theory research is used to generate theories about clinical practice and understanding about multiple aspects of health care. Meta-synthesis, also called meta-summary, is a rigorous synthesis of a critical mass of qualitative research evidence that relates to answering a specific research question.

6. Which of the following statements about grounded theory is true? a.

The primary purpose of grounded theory research is development of a theory that emerges from data about relevant social processes which can then be applied to clinical practice.

Univariate analysis is used in the grounded theory process to examine data from interviews.

Grounded theory as a method is rooted in biology.

The approach to grounded theory is deductive.

ANS: A

Grounded theory research is used to generate theories about clinical practice and understanding about multiple aspects of health care. For grounded theory, the constant comparative method of data analysis is used to examine data from interviews, identify gaps in understanding from the data, and conduct additional interviews until data saturation occurs. Univariate analysis is used to describe one variable. Grounded theory as a method is rooted in sociology, specifically symbolic interactionism, which describes the relationship between people and society. The approach to grounded theory is inductive and has clearly developed systematic procedures designed to develop a theory or basic social process. 7. An advanced practice nurse has been asked to speak to a group of undergraduate nursing students regarding ethnography as an

approach to qualitative research design. Which of the following statements will the nurse include? a.

Ethnography is associated with anthropology.

The purpose of ethnography is to identify specific disease processes associated with ethnic groups.

Data for ethnography consists solely of participant responses to interview questions.

The outsider’s view of the participants world is called “emic.”

ANS: A

Ethnography is associated with anthropology, the work of describing culture and the people of a particular culture. The purpose of ethnographic research is to discover and understand the social and psychological culture existing within a group of people. Data for ethnographic research can include artifacts of the culture such as clothing, jewelry, cooking implements, and ceremonial objects. The “emic” view is the participants’ view of their world and the “etic” view is the outsiders’ view of the participant’s world. 8. A nurse manager developed and implemented a staff retention program for all nurses on the unit. The manager plans to use a

qualitative research design incorporating the case study approach to review the program. The manager should a.

not follow the case study approach as more than one person will be studied.

realize that case studies apply only to the specific geographic location where the study takes place.

pose questions to begin the case study data collection and grow the questions as data are collected.

review anthropology as it is the basis of the case study approach.

ANS: C

A single case may be an individual, a family, a community, or an organization. Case studies emphasize a holistic approach to the research that may lead to the identification of patterns consistent across a set of cases that contribute to a more global understanding of a particular problem. To begin a case study, researchers pose questions understanding that the initial questions are never all inclusive. The researcher should use an iterative process of “growing questions” in the field. As data are collected, other questions emerge and serve to guide the researcher’s quest to untangle the complexities the case. Case study research is rooted in sociology and focuses on describing elements of an individual case including the commonalities and the peculiarities. 9. A group of health care providers are concerned about development of depression after discharge to home in patients who survived

sudden cardiac arrest. A member of the group volunteers to complete a meta-synthesis of qualitative research evidence to answer the clinical question, “Do survivors of sudden cardiac arrest develop depression after discharged to home? When preparing a meta-synthesis the researcher should do all of the following except: a.

formulate a quantitative research question.

identify, select, and critically appraise relevant studies.

abstract, synthesize, and lend further interpretation to the body of study findings. 3

draw overall conclusions.

ANS: A

Steps to formulate a meta-synthesis: (1) formulate a qualitative research question, (2) identify, select, and critically appraise relevant studies, (3) abstract, synthesize, and lend further interpretation to the body of study findings, (4) draw overall conclusions are all components of preparing a meta-synthesis. 10. When gathering data to answer the clinical question, “What is it like to wait for results of a bone marrow biopsy?” The investigator

is most likely to gather qualitative data that includes the participants? a.

Weight before and after the bone marrow biopsy

Thoughts while awaiting the results

Level of pain on a scale of 1 to 10 immediately after the procedure

Number of minutes spent in rapid eye movement (REM) sleep the night of the bone marrow biopsy

ANS: B

Data gathered via qualitative research methods include thoughts, feelings, behaviors, and actual lived experiences as told by the individuals experiencing the phenomenon being investigated. The other options are considered to be numeric rating scales most often used in quantitative research.

11. The sampling strategy in qualitative research has the primary goal of a.

controlling contextual elements.

eliminating contextual elements.

obtaining a predetermined number of participants to gain statistical significance.

collecting raw data from individuals experiencing the phenomena being studied and describing the phenomena from the perspective of the individuals actually living it.

ANS: D

Sampling strategies in qualitative research have as their primary goal the collection of raw data from individuals experiencing the phenomena being studied with the goal of describing the phenomena from the perspective of the individuals actually living it. The other options are not components of qualitative research sampling strategies. 12. A mentor is questioning a new researcher regarding qualitative data analysis. Which statement by the new researcher indicates the

need for further clarification by the mentor? a.

“Qualitative data consist of words rather than numbers.”

“Qualitative data are analyzed by mathematical manipulation.”

“The researcher reads transcripts from participant/researcher interviews and extracts meaning from the repetitive patterns of words emerging from the raw data.”

“The researcher must use a systematic process to describe thoroughly to the reader the process of how the researcher arrived at their conclusions.”

ANS: B

Qualitative data are analyzed by interpretation rather than mathematical manipulation used for quantitative data. All of the other statements about qualitative data analysis are correct. 13. Which of the following is associated with qualitative research? a.

Outcomes are of primary concern rather than process.

Relationships among variables are studied in qualitative research.

The “why” something has occurred is described.

How many times a particular result occurred is the focus.

ANS: C

Qualitative approaches are used to describe the “why” something has occurred. Process is of primary concern for qualitative research and outcomes are of primary concern for quantitative research. Relationships among variables, the effect of an intervention on an outcome, what has occurred, and how many times something has occurred are addressed by quantitative approaches. 14. All of the following are terms to describe criteria for determining the trustworthiness of qualitative research except a.

generalizability.

dependability.

credibility.

transferability.

ANS: A

Criteria for determining the trustworthiness of qualitative research were introduced in the 1980s when they replaced terminology for achieving rigor, reliability, validity, and generalizability with dependability, credibility, and transferability. 15. Which one of the following is a criteria to critique the quality and rigor of qualitative research? a.

Confirmability

Validity

Reliability

Objectivity

ANS: A

In quantitative research, rigor is judged in terms of a study’s validity, reliability, generalizability, and objectivity. Measures of quality for qualitative research include credibility, transferability, dependability, and confirmability. 5

TRUE/FALSE

1. Qualitative research is explanatory, descriptive, and inductive in nature and is comprised of methods that help us formulate an

understanding of phenomena and their context answered by discovery-oriented research questions. ANS: T

Qualitative research is explanatory, descriptive, and inductive in nature and is comprised of methods that help us formulate an understanding of phenomena and their context answered by discovery-oriented research questions. 2. Phenomenology is research used to generate theories about clinical practice and understanding about many different aspects of

health care. ANS: F

Phenomenology is a science whose purpose is to describe particular phenomena, or the appearance of things, as lived experience. Grounded theory research is used to generate theories about clinical practice and understanding about many different aspects of health care. 3. Ethnography is associated with genealogy.

ANS: F

Ethnography is associated with anthropology, the work of describing culture, and the people of a particular culture. Genealogy studies family history and traces lineage.

4. Etic is the insiders’ view of culture.

ANS: F

Emic is the insiders’ view of a culture and etic is the outsider’s view of a culture. 5. Transferability refers to the conscious effort to establish confidence in an accurate interpretation of the meaning of the data.

ANS: F

Transferability focuses on whether the findings are applicable outside the study situation. Credibility refers to the conscious effort to establish confidence in an accurate interpretation of the meaning of the data. 6. Dependability refers to whether the informants recognize the exhaustive description as their reality when the narrative is returned to

them. ANS: T

Dependability refers to whether the informants recognize the exhaustive description as their reality when the narrative is returned to them. 7. Purposive sampling refers to a sample that is homogenous and reflects the population being studied.

ANS: T

Purposive sampling is homogenous and reflects the population being studied. 8. Meta-synthesis is a rigorous synthesis of a critical mass of qualitative research evidence that relates to answering a specific

research questions. ANS: T

Meta-synthesis is sometimes called a meta-summary which can be described as a rigorous synthesis of a critical mass of qualitative research evidence that relates to answering a specific research question. 9. Qualitative research is explanatory, descriptive, and inductive in nature and is comprised of methods that help us formulate an

understanding of phenomena and their context answered by discovery-oriented research questions. ANS: T

Qualitative research is explanatory, descriptive, and inductive in nature and is comprised of methods that help us formulate an understanding of phenomena and their context answered by discovery-oriented research questions. 10. Criteria to evaluate qualitative findings have evolved to be as transparent as quantitative critiquing guidelines.

ANS: F

Criteria to evaluate qualitative findings have been evolving, but may not be as transparent as quantitative critiquing guidelines. 11. Evidence hierarchy includes qualitative studies as providing strong level II evidence.

ANS: F

Evidence hierarchy includes qualitative research which is ranked as providing weaker level VI evidence. 12. The strength of evidence by qualitative studies is currently misrepresented since the linear approach used to evaluate quantitative

studies such as randomized controlled trials (RCT) does not align with the nonlinear nature of qualitative research. ANS: T

The strength of evidence by qualitative studies is currently misrepresented since the linear approach used to evaluate quantitative studies such as randomized controlled trials (RCT) does not align with the nonlinear nature of qualitative research. There is the need for a different paradigm for critically appraising the strength and quality of the evidence provided by the findings of qualitative studies so that the evidence provided by the findings are valued as important data that inform clinical practice about the patient experience. 7

13. Credibility refers to the conscious effort to establish confidence in an accurate interpretation of the meaning of the data.

ANS: T

Credibility refers to the conscious effort to establish confidence in an accurate interpretation of the meaning of the data. 14. Findings of qualitative research may be used for instrument development.

ANS: T

Qualitative research is most valuable when expressing patient’s stories and should be applied in areas where there is need to build theory which may then lead to quantitative studies and instrument development.

Chapter 10: Understanding Statistics for Evidence-Based Practice LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. All measurements in science are based on all but which one of the following scales? a.

Regular

Ratio

Interval

Ordinal

ANS: A

All measurements in science are conducted using four different types of scales: nominal, ordinal, interval, and ratio. 2. Data such as satisfaction level where the choices are highly satisfied, neutral and not satisfied are an example of which type of

data? a.

Nominal

Ordinal

Interval

Ratio

ANS: B

Ordinal data is a set of data that has some kind of hierarchy to it but the intervals between values may not be easily interpretable. An example of ordinal data is a satisfaction survey. Nominal data, also called categorical data, is not numerical and there is no established hierarchy between values. An example of nominal data would be the state you live in. Interval data consists of values that are numeric, there is hierarchy to the data and the intervals between categories have consistent, set values that are easily understood across multiple individuals. An example would be temperature of a room. Ratio data has all of the characteristic of interval data but includes absolute zero. 3. When reviewing distribution of data in descriptive statistics the “n” reported represents? a.

The control group

The experimental group

The frequency

The nominal data

ANS: C

When reviewing distribution of data in descriptive statistics the “n” represents the frequency. 4. When reviewing results of a study, the reader would like to know how far the variables are spread from the mean. Which

descriptive analysis would be most helpful to the reader? a.

Standard deviation (SD)

Distribution of data

Range

Mode

ANS: A

Standard deviation is an indication of how far the variables are spread from the mean. Distribution of the data is directly related to the variation of the data. Range is the lowest and the highest values reported, and mode is the value that occurs most frequently in the data set. 5. A researcher wants to compare stress levels, as reported on a 5 point Likers scale, in a single group of nursing students before and

after implementation of a mindfulness based stress reduction progam. Which type of statistical analyss is most appropriate? a.

Two sample t-test

Paited t-test

Analysis of variance (ANOVA) 1

Pearson coefficient correlation

ANS: B

The paired t-test is used to compare two quantitative measurments taken from the same individual. A two-sample t-test would be used to compare means between two distinct/independent groups. ANOVA is used to compare means between three or more distinct/independent groups and Pearson coefficient of correlation is used to estimate the degree of association between two quantitative variables. 6. When describing testing for significance or hypothesis testing framework to novice members of a research team, the mentor should

include which of the following statements? a.

The null hypothesis assumes there is a relationship between the two variables.

Type I error is the failure to reject a false null hypothesis.

Type II error is the rejection of a true null hypothesis.

The alpha level is the significance level which is the probability of committing the type I error.

ANS: D

The alpha level is the significance level which is the probability of committing the type I error. It is typically set at 0.05 which means there is a 5% risk when there is a significant finding of rejecting a true null hypothesis. To perform a test of significance, the researcher assumes that there is no relationship between the two variables, this is a null hypothesis. Type I error is the rejection of a true null hypothesis, and type II error is the failure to reject a false null hypothesis.

7. Which of the following will the researcher calculate to determine the proportion of patients in the control group in which an event

is observed? a.

Relative risk (RR)

Control event rate (CER)

Experimental event rate (EER)

Absolute risk reduction (ARR)

ANS: B

Control event rate is the proportion of patients in the control group in which an event is observed. Relative risk is the risk of the event after experimental treatment as a percentage of original risk. The experimental event rate is the proportion of patients in the experimental treatment groups in which an event is observed. Absolute risk reduction is the value that tells us the reduction of risk in absolute terms. 8. When reviewing specificity in the data analysis component of a report, the researcher identifies which of the following statements

as being true? a.

Specificity is the test’s ability to correctly designate a subject with the disease as positive.

Tests with low specificity will screen negatively.

A highly specific test means that there are few false positive results.

The gold standard test is not a component used for review of specificity.

ANS: C

A highly specific test means that there are few false positive results. Sensitivity is the test’s ability to correctly designate a subject with the disease as positive. Specificity is the test’s ability to correctly designate a subject without the disease as negative. Tests with low specificity have the disadvantage that many subjects without the disease will screen positive and potentially receive unnecessary follow-up diagnostic or therapeutic procedures. The gold standard is the single test that is considered the current preferred method of diagnosing a particular disease. It should be used by the researcher to populate the table to compare testing information of new test or nursing interventions. 9. When reading a meta-analysis study, the researcher reviews the statistical analysis section of the report. Which of the following

will most likely be a component of the statistical analysis section of a meta-analysis study? a.

Odds ratio

Single data points

Pie-graph charts

Studies reviewed reported together as a whole through measures of central tendency

ANS: A

The relative risk, commonly called the odds ratio is the statistic of choice for use in meta-analysis. Meta-analysis often reports on continuous data, typically the mean difference in outcomes. Blobograms, a pictorial representation to display data, is the usual manner of displaying data for a met-analysis. The findings from each individual study are presented. 10. A researcher is reviewing a study that investigated the development of asthma in children who were diagnosed with respiratory

syncytial virus in the first 3 months of life. The odds ratio was calculated to be 1. What does this mean? a.

The null hypothesis was accepted.

The null hypothesis was rejected.

Respiratory syncytial virus did not affect odds of asthma.

Respiratory syncytial virus was associated with higher odds of asthma development.

ANS: C

Prognosis studies often use longitudinal cohort design. At the conclusion of a longitudinal study, investigators statistically analyze data to determine which factors are strongly associated with study outcomes usually through a technique called multivariate regression analysis or simply multiple regression. If the odds ratio is = 1 or the confidence interval = 1, exposure does not affect odds of outcome. If the odds ratio is greater than 1 and the confidence interval does not include 1, exposure is associated with higher odds of outcome.

11. When outcome predictions are made before the measurement phase begins, the practice is referred to as a.

positive predictive value.

likelihood ratio.

clinical meaningful.

a priori.

ANS: D

A priori refers to outcome predictions that are made before the measurement phase begins. Positive predictive value expresses the proportion of those with positive test results who truly have the disease. Likelihood ratio expresses the magnitude by which the probability of disease in a specific patient is modified by the result of a test. Clinical meaningful reflects the degree to which the differences and relationships reported in a study are relevant to nursing practice. 12. A researcher wishes to apply findings from a sample onto a population. To do this the research must utilize a.

descriptive statistics.

inferential statistics.

nonparametric statistics.

parametric statistics.

ANS: B

Inferential statistics are tests used to apply findings from a sample onto a population. Descriptive statistics are used to describe, or summarize elements of the sample. Nonparametric statistics are distribution free statistical methods used to analyze nominal and ordinal level data, and parametric statistics are used to analyze data at the interval or ratio level with the parameters tested having normal distribution in the population.

13. When a research team develops conclusions from their study and report that the findings are significant when they actually are not,

the situation is referred to as a.

type I error.

type II error.

null value.

negative predictive value.

ANS: A

When a researcher states that the findings are significant when they are not, the situation is referred as type I error. This is serious because evidence used to change practice can lead to wrong conclusions and perhaps inappropriate changes in practice. Type II error occurs when an instrument, or test, incorrectly predicts that a phenomenon of interest will not occur. Null value is the value of no effect; in experimental study design it often means there is no difference in the outcomes between the experimental and control group. Negative predictive value expresses the proportion of those with negative test results who truly do not have disease. 14. To reduce the probability of committing a type II error, researchers often conduct which type of analysis? a.

P-value

Receiver operating characteristic (ROC) curve

Power analysis

Standard deviation

ANS: C

A power analysis is a method of determining statistical power which is the probability of correctly rejecting a null hypothesis. A probability value, p-value, is a numeric value that helps determine whether the null hypothesis should be rejected or accepted. A ROC curve is a plot of the true positive rate against the false positive rate for different possible cut points of a diagnostic test. Standard deviation is a numeric measure of the variation or spread of values in a set of data. 15. When reading study results, which of the following provides information on the clinical meaningfulness of the results? a.

Confidence interval

“p-value”

Alpha level

Beta level

ANS: A

Clinical meaningfulness reflects the degree to which the differences and relationships reported in a study are relevant to nursing practice. Confidence intervals help the clinician provide clinical meaningfulness to study results. A confidence interval represents a range of values within which a given population parameter may be expected to fall. Typically, confidence intervals are set at 95% of certainty. P-value represents the probability of an event or outcome occurring in repeated trials under similar conditions. The alpha level is the significance level which is the probability of committing a type I error. The risk of making a type II error is denoted as the beta level.

TRUE/FALSE

1. Continuous data is a variable that measures a degree of change or difference on a range.

ANS: T

Continuous data is a variable that measures a degree of change or difference on a range. 2. Incidence is the epidemiologic term used to describe the number of people with a disease at a specified time period.

ANS: F

Incidence is the epidemiologic term used to describe the number of people who will develop a disease during a specified time period and prevalence is the epidemiologic term used to describe the number of people with a disease at a specific time period. 3. Descriptive statistics are tests used to apply findings from a sample onto a population.

ANS: F

Inferential statistics are tests used to apply findings from a sample onto a population and descriptive statistics are used to describe, 5

or summarize elements of the sample. 4. The mode is the value in a set which is most close to the middle of a range.

ANS: F

The mode is the value which occurs most frequently in a data set. The mean is the average of all the data in a set and the median is the value in a set which is most close to the middle of a range. 5. Nominal data is a type of data that is not numerical and with no established hierarchy between values.

ANS: T

Nominal data is a type of data that is not numerical and with no established hierarchy between values. 6. The null hypothesis is a hypothesis that assumes there is no relationship between two variables.

ANS: T

The null hypothesis is a hypothesis that assumes there is no relationship between two variables. 7. Power analysis is a method of determining statistical power which is the probability of correctly accepting a null hypothesis.

ANS: F

Power analysis is a method of determining statistical power which is the probability of correctly rejecting a null hypothesis.

8. Specificity is the ability of the instrument or test to predict a positive test result when the phenomenon of interest is also positive or

will occur. ANS: F

Specificity is the ability of the instrument or test to predict a negative test result when the phenomenon of interest is also negative or will not occur. Sensitivity is the ability of the instrument or test to predict a positive test result when the phenomenon of interest is also positive or will occur. 9. Type I error occurs when an instrument or test incorrectly predicts that a phenomenon of interest will occur, and type II error

occurs when an instrument or test incorrectly predicts that a phenomenon of interest will not occur. ANS: T

Type I error occurs when an instrument or test incorrectly predicts that a phenomenon of interest will occur, and type II error occurs when an instrument or test incorrectly predicts that a phenomenon of interest will not occur. 10. Ordinal data is a type of data that is not numerical and with no established hierarchy between values.

ANS: F

Ordinal data is a type of non-numerical data that has an associated hierarchy but the distance between values may not be consistent and may have different interpretations. Nominal data is a type of data that is not numerical and with no established hierarchy between values.

11. When the data are normally distributed, they are considered to be parametric.

ANS: T

When the data are normally distributed, they are considered to be parametric. Nonparametric statistics are distribution free statistical methods used to analyze nominal and ordinal data.

Chapter 11: Evidence-Based Approaches for Improving Health Care Quality LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. Which of the following statements about benchmarking is true? a.

Benchmarking is not part of quality indicators.

Benchmarking is the process of comparing practice performance for a certain task across all areas of a health care facility.

Benchmarking helps identify when performance is below an agreed-upon standard and signals the need for improvement.

To support the validity of benchmarking, it is essential to ensure that the numerator and denominator for a measure are measured differently across time among different clinical practices.

ANS: C

Benchmarking is the process of comparing practice performance with an external standard. It is an important tool that facilitators can use to motivate practice to engage in work improvement and to help members of a practice understand where their performance falls in comparison to others. Benchmarking is an important component of quality indicators. It is the process of comparing a health care facility’s performance to those of providers in other organizations who provide care to a similar patient population and who use the same measures to document care. To support the validity of benchmarking, it is essential to ensure that the numerator and denominator for a measure are defined and measured in the same manner across time and among different clinical practices. 2. The quality improvement model emphasizes all of the following except a.

cost reduction.

customer satisfaction.

teams and teamwork.

continuous improvement of work processes.

ANS: A

The quality improvement model emphasizes customer satisfaction, teams and teamwork, and the continuous improvement of work processes. 3. The major quality improvement models used today in health care include all of the following except a.

Total quality management/continuous quality improvement (TQM/CQI).

Six sigma.

Quality assurance.

Lean.

ANS: C

Historically, the quality of health care was assessed retrospectively using the quality assurance model. The major quality improvement models used in today’s health care settings include; TQM/CQI, six sigma, lean, and clinical microsystems. 4. The first step in the quality improvement approach is a.

analyzing data to identify a problem in need of improvement.

assessing health system performance by collecting and monitoring data.

developing a plan to treat the identified problem.

implementing the improvement plan.

ANS: B

Steps in the quality improvement process include: assessing health system performance by collecting and monitoring data, analyzing data to identify a problem in need of improvement, developing a plan to treat the identified problem, and testing and implementing the improvement plan. 5. A bar chart used to illustrate a project’s schedule is referred to as a a.

Gantt chart. 1

histogram.

line chart.

scatter plot.

ANS: A

A Gantt chart is a type of bar chart used to illustrate a project’s schedule. A histogram is a graphical representation of the distribution of numerical data. A line chart or line graph is a type of chart which displays information as a series of data points called “markers” connected by straight line segments. A scatter graph is a type of mathematical diagram using Cartesian coordinates to display values for typically two variables for a set of data. 6. A researcher wishes to understand the frequency of factors that contribute to a common effect. Which of the following should the

researcher use? a.

Ishikawa diagram

Histogram

Pareto diagram

Bar chart

ANS: C

A Pareto diagram is a special type of bar chart used to understand the frequency of factors that contribute to a common effect. It is used to display the Pareto principle. A histogram is another type of bar chart used for continuous-level data to show the distribution of the data around the mean, commonly called the bell curve. An Ishikawa diagram is a cause and effect diagram used to identify and treat the causes of performance problems. A bar chart is used to display categorical-level data.

7. Which of the following statements about root cause analysis (RCA) does the nurse identify as being true? a.

Use of a fishbone diagram retrospectively during RCA can be used to identify system design failures that caused errors.

The goal of a RCA is to identify blame.

A Venn diagram is useful in RCA to identify the chain of cause.

The most effective RCAs include dismissal of the individual responsible for the mistake.

ANS: A

Retrospective use of a fishbone diagram can be used during RCA to identify system design failures that cause errors. The goal of a RCA is to learn from mistakes and mitigating hazards that arise as a characteristic of the system design. A tree diagram is useful for identifying the chain of causes with the goal of identifying the RCA of a problem. A Venn diagram (also known as a set diagram or logic diagram) is a diagram that shows all possible logical relations between a finite collection of different data sets. The most effective RCAs include a change in practice or work system design to lessen the chances of similar errors occurring in the future. 8. A nurse is leading an improvement team which has pinpointed a problem in need of improvement. The nurse leader guides the

group into the phase to treat the performance problem by initiating which of the following as the first step of this phase? a.

Aim

Measures

Changes

Ideas

ANS: A

Aim is the first step of the process. When completing this step, the group determines what they are trying to accomplish by developing a clear aim with specific measurable targets. The next step is measures to determine how the group will know that the change is an improvement. In this phase, qualitative and quantitative measures to support real improvement work to guide the change progress toward the stated goal are used. The final step is changes. In this final step, the group determines what changes can be made that will result in an improvement. A statement is developed about what the team believes they can change to cause improvement. 9. The nurse leader identifies the focus of plan-so-study-act (PDSA) improvement process step as a.

gathering data.

experimentation using small and rapid tests of change.

analyzing data.

summarizing results.

ANS: B

The focus of PDSA is experimentation using small and rapid tests of change. In this step, evaluation of the success of the intervention in bringing about improvement occurs. 10. Current evidence from primary care suggests that organizational-level strategies such as practice facilitation are consistently

effective with promoting compliance with desired practice when which of the following strategies is incorporated? a.

Audit and feedback

Workshops

Educational meetings

Educational outreach

ANS: D

Current evidence from primary care shows that educational outreach visits demonstrated the largest median change in compliance with desired practice compared to no strategy followed by; educational meetings and workshops, audit and feedback, computerized reminders, printed educational materials, and use of local opinion leaders. Evidence for use of financial incentives and multiple versus single implementation strategies is currently mixed and inconclusive.

TRUE/FALSE

1. The nursing profession began participation in quality improvement initiatives in the early 1980s.

ANS: F

Florence Nightingale championed quality improvement by systematically documenting high rates of morbidity and mortality resulting from poor sanitary conditions among soldiers serving in the Crimean War of 1854. 2. Special cause variation occurs at random and is considered a characteristic of the system.

ANS: F

Special cause variation arises from a situation that disrupts the causal system beyond what can be accounted for by random variation. Common cause variation occurs at random and is considered a characteristic of the system. 3. Variations in system performance over time are commonly displayed with run charts and control charts.

ANS: T

Variations in system performance over time are commonly displayed with run charts and control charts. 4. A run chart includes information on the average performance level for the system depicted by a center line displaying the system’s

average performance and the upper and lower limits depicting one to three standard deviations from average performance level. ANS: F

A control chart includes information on the average performance level for the system depicted by a center line displaying the system’s average performance and the upper and lower limits depicting one to three standard deviations from average performance level. A run chart is a graphical data display that shows trends in a measure of interest with trends revealing what is occurring over time.

5. Because quality improvement studies capture the experiences of an organization or unit, the results of these studies are usually not

generalizable. ANS: T

Because quality improvement studies capture the experiences of an organization or unit, the results of these studies are usually not generalizable. The Standards for Quality Improvement Reporting Excellence or (SQUIRE) Guidelines have been developed to promote publication and interpretation of this type of applied research. 6. The Quality Payment Program and HEDIS are sources of standardized measures to assess and improve the quality of care delivered

in the United States. ANS: T

The Quality Payment Program and HEDIS are sources of standardized measures to assess and improve the quality of care delivered in the United States. 7. Quality improvement as a management model is both a philosophy of organizational functioning and a set of statistical analysis

tools and change techniques used to reduce variation in the quality of goods or services that an organization produces. ANS: T

Improvement as a management model is both a philosophy of organizational functioning and a set of statistical analysis tools and change techniques used to reduce variation in the quality of goods or services that an organization produces.

Chapter 12: Planning for Success LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. When implementing EBP, the research team incorporates all but which one of the key areas of The Translating Research into

Practice (TRIP) model? a.

Nature of the intervention

Social system involved

Manner of communication

Governed change process

ANS: D

According to the TRIP model, adoption of EBPs is influenced by nature of the innovation such as nature of the intervention, social system involved, and manner of communication all taking part in an arena of participative, planned change. 2. The first step of successful implementation of EBPs starts with a.

action plan.

principles.

topic selection.

ethical considerations.

ANS: C

Planning for successful implementation starts with topic selection and continues throughout all steps of the EPB process. 3. A team of researchers identifies which of the following as a problem-focused trigger for EBPs? a.

Benchmarking data

Ideas from reading research publications

Encounter with EBP guidelines published by governmental agencies or specialty organizations

Listening to scientific papers presented at research conferences

ANS: A

Problem-focused triggers are those identified through quality improvement, risk surveillance, benchmarking data, financial data, or recurrent clinical problems. Knowledge-focused triggers include ideas generated when clinicians read research, listen to scientific papers at research conferences, or encounter EBP guidelines published by federal agencies or specialty organizations. 4. The leader of an evidence-based practice team is asked to discuss attributes which influence implementation of the EBP topic. The

leader will include all of the following except a.

complexity.

significance.

relative advantage.

trialability.

ANS: B

There are five attributes of the EBP topic influence on implementation: relative advantage, compatibility, complexity, trialability, and observability. 5. Following evidence synthesis and EBP recommendations set forth by the team, all but which of the following should be developed? a.

Evidence grade for each EBP recommendation

Policies

Practice standard

Explanation of what will happen to individuals who do not follow the EBP

ANS: D

Following evidence synthesis, the team should set forth EBP recommendations with an evidence grade for each. The EBP recommendations need to be converted into practice statements for the individual setting such as policies, procedures, or practice 1

standards. 6. Which of the following statements regarding quality improvement and use of metrics to facilitate implementation of EBP is true? a.

Metrics are completed only after completion of implementation of EBPs.

Metrics used for EBP implementation should remain separate from the organizations QI program.

Metrics can be used to identify the need for implementation “boosters” over time.

Metrics are difficult to understand and should therefore only be reviewed by EBP team members.

ANS: C

The EBP metrics should be tracked over time and if negative trends are noted, a review or “boost” of the EBP may be helpful. Metrics should be collected prior to, during, and upon completion of implementation. Metrics used for EBP implementation should be integrated into the organization’s QI program to evaluate sustainability of the EBP. Metrics should be shared with all members of the organization and communicated over time to facilitate implementation of the EBP.

7. Processes of care metrics are obtained during which phase of the PICO process? a.

Patient, problem (P)

Intervention, cause, outcome (I)

Comparison or control (C)

Outcome (O)

ANS: B

Process of care metrics evaluates staff use of the EBPs as detailed in the local EBP standard. This is the intervention, cause, outcome “I” component of PICO. 8. Which of the following statements about a “stable process” should the EBP team question? a.

A process is stable if it contains any special-cause variation.

A process is stable if it contains only common-cause variation.

A process must be stable before improvements are initiated.

A process is stable if it contains noise.

ANS: A

A process is stable if it does not contain any special-cause variation. A process is stable if it contains only common-cause variation. A process must be stable (no special-cause variation) before improvements are initiated. A process is stable if it contains only common-cause variation, also known as random variation, noise, or within-group variation. 9. Which statement regarding Roger’s diffusion of innovations theory should the EBP team question? a.

Decision-makers move from knowledge about an innovation through implementation and confirmation of the EBP.

People do not all adopt EBPs at the same time.

The time for implementation varies depending upon the nature and complexity of the EBP.

When 80% of individuals adopt the new EBP, there is a natural take-off in the rate of adoption.

ANS: D

All of the statements are true except for D. When 30% to 40% of individuals adopt the new idea (EBPs), there is a natural take-off (S curve) in the rate of adoption. 10. While not generalizable in the traditional sense, in-depth, qualitative data is referred to in the qualitative literature as being a.

statistically significant.

evidence based.

metaphoric generalizable.

predictive.

ANS: C

While not generalizable in the traditional sense, in-depth, qualitative data is referred to in the qualitative literature as “metaphoric generalizable.” It is essential for learning about the lived experiences of diverse populations of patients and families.

TRUE/FALSE

1. Implementation of an evidence-based practice topic is messy, iterative, and nonlinear.

ANS: T

Implementation of an evidence-based practice topic is messy, iterative, and nonlinear. It requires tenacity, commitment, and relationship building. Minimal guidance is providing for implementation in many EBP models, including the Iowa Model. 2. Implementation ends when writing and dissemination of evidence-based policies, procedures, or standards is complete.

ANS: F

Implementation goes beyond writing and disseminating evidence-based policies, procedures, or standards to clinicians. Implementation requires interactions among direct care providers to champion and foster evidence adoption, leadership support, 3

and system changes. 3. When selecting a topic, it is essential that all research team members consider how the topic fits with the priorities of their practice

agency. ANS: T

When selecting a topic, it is essential that all research team members consider how the topic fits with the priorities of their practice agency. This allows the group to garner support from leaders and the necessary resources for successful implementation. 4. Planning for implementation requires that only key team members participate in some component of implementation.

ANS: F

Planning for implementation requires that all team members participate in some component of implementation. 5. Implementation is about relationships that foster questioning, respect, and trust.

ANS: T

Implementation is about relationships that foster questioning, respect, and trust. 6. Outcome measures include only patient outcomes.

ANS: F

Outcome measures may include not only patient outcomes but also clinician outcomes such as improvement in knowledge, and fiscal outcomes such as cost avoidance, cost reductions, or revenue enhancement.

7. Achieving the desired outcomes requires decreasing variability in processes as well as shifting the process in the desired direction.

ANS: T

Achieving the desired outcomes requires decreasing variability in processes as well as shifting the process in the desired direction. 8. Variability in the process to determine whether or not the EBPs are having an impact can result in a conclusion that the EBP

intervention is not achieving the desired outcomes. ANS: T

There is a tendency to jump to the conclusion that EPB interventions are not achieving the desired outcomes when in reality there is too much variability in the process to determine whether or not they are having an impact. 9. To understand variation and common or special cause, the team must display data using only run charts.

ANS: F

Displaying data using run charts and SPEC charts is necessary for understanding variation and it is common or special cause. 10. Special-cause variation can often be tracked down and fixed without extensive changes to the system.

ANS: T

Specific cause variation is unexpected variation that results from unusual occurrences such as repeated falls by one patient. Once the special-cause variation is noted, further work is needed to determine the cause of this variation and what can be done to prevent it from happening in the future. Special-cause variation can often be tracked down and fixed without extensive changes to the system.

Chapter 13: Launching Implementation LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. Rogers suggests which as the first step for enhancing adoption of EBP interventions? a.

Persuasion

Knowledge

Decision

Implementation

ANS: B

The stages of adoption as defined by Rogers include knowledge, persuasion, decision, implementation, and confirmation. 2. The field of translation science is concerned with a.

research focused on the development and testing of interventions or implementation strategies that affect the rate and extent of EBP adoption.

the significance of the findings.

methods to encourage health care providers to participate in clinical research.

developing set criteria to follow for identifying areas in need of study.

ANS: A

The field of translation science is concerned with research focused on the development and testing of interventions or implementation strategies that affect the rate and extent of EBP adoption. 3. Which of the following would an EBP implementation team not consider as a method to facilitate adoption of the EBP? a.

Quick reference guides

Clinical decision support

Key messages at the point-of-care delivery

Detailed reports of statistical analysis of results

ANS: D

Implementation strategies such as use of quick reference guides, clinical decision support, and key messages at the point-of-care delivery have been found to positively influence adoption of EBPs. 4. An EBP team is developing a quick reference guide to facilitate adoption of a new EBP. Which of the following should the team

avoid when developing the quick reference guide? a.

Provision of the quick reference guide on-line only to avoid wasted paper

Concise information

Use of tables

Use of graphs

ANS: A

Quick reference guides should provide targeted, concise information designed to help practitioners perform specific tasks at the point of care. The quick reference guide should be clear, accurate, and accessible. The aim is to offer easily accessible information as a supplement to a longer policy or reference. 5. Clinical decision support tools are most often designed in the form of a(n) a.

Pie chart.

histogram.

algorithm.

null hypothesis.

ANS: C

Clinical decision support tools are most often designed in the form of algorithms. 6. Which of the following statements regarding opinion leaders is true? 1

Opinion leaders have no influence over adoption of EBP.

Opinion leaders tend to have little exposure to mass media.

Opinion leaders are generally inaccessible to others.

ANS: D

Opinion leaders influence a balance between being too innovative or heterogeneous and keeping the homophily within the group that leads to credibility and trust in their judgment and evaluation of new clinical practices. Opinion leaders have a great deal of influence on the adoption of EBP and generally have a lot of exposure to mass media. Opinion leaders are usually widely connected with other individuals and groups and are accessible to their followers who are usually members of their own peer group. 7. Which of the following is not a method used to identify opinion leaders? a.

Sociometric method

Use of key informants

Significance process

Self-designating technique

ANS: C

There are four methods that are useful for identifying opinion leaders. They include: sociometric, use of key informants, self-designating technique, and observation method.

8. Which of the following is a characteristic of a change champion? a.

Change champions evaluate new practices.

Change champions actively advocate for practice change.

Change champions influence others based on their expertise.

Change champions are always members of the organization’s executive level.

ANS: B

Change champions actively advocate for practice change. Opinion leaders evaluate new practices. The influence of change champions is based on persuasion with their personal and organizational network and is often project specific. Change champions can come from all levels of an organization. 9. Which of the following is not a component of academic detailing? a.

Provision of feedback on provider or team performance of an EBP recommendation

Explanation of the research foundation of the EBP

Expertise on a particular topic

Interaction with others within the research setting with no contact in individual practice settings

ANS: D

Educational outreach/academic detailing provides feedback on provider or team performance of an EBP. Academic detailers are able to provide an explanation of the research foundation for the EBP and have expertise in a particular area. Academic detailers are involved with interactive face-to-face education of individual practitioners in their practice setting. 10. According to Moore and colleagues, the definition of sustainability includes all but which one of the following constructs? a.

The program and individual behavior is static.

Among potential influences on sustainability are the innovation characteristics.

Integration with organizational governance structures is a component of sustainability.

Sustainability is determined after a defined period of time.

ANS: A

Moore and colleagues arrived at a definition of sustainability that includes five constructs: (1) after a defined period of time, (2) the program, clinical intervention, and/or implementation strategies continue to be delivered and/or (3) individual behavior change (i.e., clinician, patient) is maintained; (4) the program and individual behavior change may evolve or adapt while (5) continuing to produce benefits for individuals/systems.

TRUE/FALSE

1. Homopholous is defined as the transfer of ideas between opposite or different groups.

ANS: F

Homopholous is defined as the transfer of ideas that occurs most often among groups or people who are similar. Heteropholy is defined as the transfer of ideas between opposite or different groups. 2. TRIP is a broad framework explaining the adoption of many types of innovations by various groups or populations.

ANS: F

DOI is a broad framework explaining the adoption of many types of innovations by various groups or populations. TRIP is the application of the broad framework of DOI to the more focused translation of innovative evidence-based practice in health care. 3. The TRIP model stresses the importance of communication during the implementation stage of an EBP project and for sustaining

the practice change. ANS: T

The TRIP model stresses the importance of communication during the implementation stage of an EBP project and for sustaining the practice change. 3

4. The rate of adoption refers to the number of users of the EBP after the implementation compared to before the project.

ANS: F

The rate of adoption refers to the speed in which the users begin in use the new EBPs. The extent of adoption refers to the number of users of the EBP after the implementation compared to before the project. 5. Clinical decision support is a core function of electronic health records.

ANS: T

Clinical decision support is a core function of electronic health records. Empirical support for the effectiveness of clinical decision support embedded in electronic health records is mixed and research involving nurses and patient outcomes is limited. 6. The primary sources of mass media are television, radio, print, and internet sources.

ANS: T

The primary sources of mass media are television, radio, print, and internet sources.

7. A change champion and an opinion leader have the same characteristics.

ANS: F

Champions actively advocate for practice change. Although the terms change champion and opinion leader are often used interchangeably, there are conceptual differences. Some of the similarities of the two include: both are individual, informal social influence roles that are internal to an organization or system and rely upon ongoing relationships. Neither opinion leaders nor champions need to be specifically trained or chosen for the role; they may instead emerge within a context based on the needs of the local organization. Opinion leaders evaluate new practices, are influential based on their expertise relative to their domain such as patient care unit or specialty. Champions actively advocate for practice change. 8. Implementation planners should consider sustainability of the EBP from the very beginning of the project.

ANS: T

Building the evidence base about sustainability is currently a high priority for implementation scientists. Guided by the TRIP model, implementation, planners should consider sustainability of the EBP from the very beginning of the project.

Chapter 14: Implementation Strategies for Stakeholders LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. When discussing performance gap assessment (PGA) with members of a team, the nurse leader includes which of the following

statements? a.

PGA is defined as the end point practice performance after implementation of the EBP change.

PGA is used to engage clinicians in discussions of practice issues.

The first step of PGA is to illustrate the current state of practice with indicators.

The last step of PGA is to select the practice performance indicator to use.

ANS: B

PGA is used to engage clinicians in discussions of practice issues and formulation of strategies to promote alignment of their practices with EBP recommendations. Performance gap assessment is defined as the baseline practice performance, which provides information about the state of current practices at the beginning of the practice change. The second step of PGA is to illustrate the current state of practice using identified indicators. The first step of PGA is to select the practice performance indicators to use followed by illustrating the current state or practice using these indicators; selecting a venue for discussing the gap between the current practice indicators and recommendations based on evidence and finally engaging clinicians in a dialog about improving practices to align with the evidence. 2. A nurse leader is overseeing audit and feedback of performance indicators. The nurse leader would need to intervene when one of

the team members a.

audits the performance indicators on a regular basis throughout the implementation process.

aggregates the data into reports.

discusses the findings with practitioners on a regular basis during the practice change.

withholds information from practitioners until the implementation phase is complete.

ANS: D

Audit and feedback is ongoing auditing of performance indicators, aggregating data into reports, and discussing the findings with practitioners on a regular basis during the practice change. This strategy helps staff see how their efforts to improve care and patient outcomes are progressing throughout the implementation process. 3. A research team is investigating methods to increase patient mobility after bariatric surgery. The team should take context factors

into considering when implementing the change. Context factors include all of the following except a.

organizational capacity for EBP change.

patient satisfaction surveys.

leadership support.

practice climates for use of EBP.

ANS: B

Context refers to the characteristics of the physical setting of implementation and the dynamic practice factors in which implementation processes occur. They include organizational capacity for EBP, leadership support, practice climates for use of EBPs, and EBP competencies of staff and nurse managers. 4. A nurse who has been charged with building an evidence-based practice culture in a health care facility has joined the

organizational team. When assessing the organizational capacity for EBP, the nurse identifies which of the following as needing attention prior to building an evidence-based practice culture? a.

Strong leadership

Effective data-capture systems

Vague strategic vision

Good managerial relations 1

ANS: C

Organizational capacity is important for building an evidence-based practice culture. Components of organizational capacity for EBP include: strong leadership, clear strategic vision, good managerial relationship, visionary staff I key positions, a climate conducive to experimentation and risk taking, and effective data-capture systems. 5. When working with senior leadership to promote use of EBPs, which of the following behavior of the senior leadership team would

the EBP implementation team identify as being counterproductive to their efforts? a.

EBP is not included in the staff’s performance expectations.

Organizational mission, vision, and strategic plan incorporate EBP.

EBP is integrated into the governance structure of the health care system.

Creation of microsystems that value and support clinical inquiry by the nurse leaders

ANS: A

To promote use of EBPs senior leadership needs to: create an organizational mission, vision, and strategic plan that incorporates EBP, implement performance expectations for staff that include the work of EBP, integrate the work of EBP into the governance structure of the health care system, demonstrate the value of EBPs through administrative behaviors, and establish explicit expectations that nurse leaders will create microsystems that value and support clinical inquiry.

6. When performing an environmental scan, the EBP implementation team would do all of the following except a.

assess internal strengths and challenges for a specific topic.

assess the institutions compliance with regulatory bodies.

assess the organizational climate for implementation.

assess the mission, vision, and values of the organization.

ANS: B

An environmental scan is a process that assesses internal strengths and challenges for case implementation of EBPs. They include structure and function of the organization, as well as understanding the mission, vision, and values to articulate how your EBP project contributes to meeting these organizational attributes. 7. After completing The Implementation Climate Scale (ICS) and Implementation Leadership Scale (ILS), data should be a.

identified to the individual completing the scale.

aggregated for reporting.

reported on an individual basis.

compared ILS and ICS across units is not helpful.

ANS: B

Individual responses from ILS and ICS should be treated as confidential and results should be aggregated for reporting. Compared ILS and ICS across units is helpful to guide implementation but the units should be blinded. 8. The nurse who is the leader of an EBP project team should initially meet with which of the following to describe the project and

overall goals related to quality and safety. a.

Board of directors of the institution

National EBP board

Chief financial officer

Chief nurse executive

ANS: D

The purpose of the meeting with the chief nurse executive is to garner support for preceding with the project and the overall implementation plan.

TRUE/FALSE

1. Performance gap assessment is defined as the baseline practice performance which provides information about the state of current

practices at the end of a practice change. ANS: F

Performance gap assessment is defined as the baseline practice performance which provides information about the state of current practices at the beginning of a practice change. 2. Use of an evidence-based practice for a period of time prior to full adoption is referred to as the pilot.

ANS: T

Trying an evidence-based practice for a period of time prior to full adoption is referred to as piloting the EBP. 3. Audit and feedback reports are more effective when they are disseminated regularly and are used to discuss practice with staff

rather than passive dissemination to selected individuals. ANS: T

Audit and feedback reports are more effective when they are disseminated regularly and are used to discuss practice with staff rather than passive dissemination to selected individuals. 4. Users of EBP usually try a practice for a period of time (pilot) before adopting it in their practice.

ANS: T

Users of EBP usually try a practice for a period of time (pilot) before adopting it in their practice. When an EBP is piloted as part of 3

implementation, users have an opportunity to use it, provide feedback to those in charge of implementation, and modify the practice if necessary. 5. Patients and families should not be included in the implementation processes of EBP.

ANS: F

As recipients of health care practices, patients/families should be incorporated into the implementation processes of EBP. 6. Providing recognition and rewards has been found to positively influence ongoing sustainability of the practice change following

implementation. ANS: T

Principles that are essential for ongoing sustainability of the practice change following implementation include: conduction an environmental scan, meeting with key leadership stakeholders, revising practice standards and documentation systems, and providing recognition and awards. 7. Currently there is a dearth of tools with good reliability and validity available for assessment of unit climate and leadership

behaviors for EBP implementation. ANS: F

A variety of tools with good reliability and validity are available for assessment of unit climate and leadership behaviors for EPT implementation including the Implementation Climate Scale and the Implementation Leadership Scale.

8. There are two version of the Implementation Leadership Scale (ILS); one for staff to report their perceptions of their supervisor’s

leadership and another for supervisor/leaders to assess themselves. ANS: T

There are two version of the Implementation Leadership Scale (ILS); one for staff to report their perceptions of their supervisor’s leadership and another for supervisor/leaders to assess themselves. 9. Engaging nurse managers early in the planning and implementation process of EBPs is essential to assure their support for

implementation. ANS: T

Engaging nurse managers early in the planning and implementation process of EBPs is essential to assure their support for implementation. An organizational meeting with the nurse manager covering the following is suggested; overview of the project, EBPs, timeline and rationale for the practice change, their commitment to implementation, and a discussion of the role of the nurse manager in implementation. 10. It is important that written standards of practice and documentation systems support use of the EBPs.

ANS: T

It is the role of leadership to ensure that organizational documents and systems are flexible and supportive of the EBPs. Clinical information systems may need revision to support practice change such as documentation systems.

Chapter 15: Patient-Centered Evidence-Based Practices LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. A nurse practitioner is caring for a 28 year patient recently diagnosed with stage 4 ovarian cancer. A barrier to shared

decision-making would be for the nurse practitioner to a.

tell the patient which treatment option he or she would choose.

ensure the patient understands their treatment options.

encourage the patient to determine their own preferences.

suggest the patient examine her beliefs.

ANS: A

Patients need to fully understand their treatment options and evaluate their own preferences and beliefs to make an informed decision and truly engage in their health decision-making. It is not appropriate to tell patients what to do. 2. Which of the following is not a component of a shared decision-making aid? a.

Incorporation of counseling

Integration of clinical judgment

Inform the patient of their values

Inclusion of risks

ANS: C

Shared decision-making aids are defined as evidence-based documents or tools that portray health care options; give information about risks, benefits, and outcomes for the options; assist the patient to clarify their values; and incorporate clinical judgment and counseling. 3. Which statement by a colleague regarding decision-making aids should the nurse practitioner question? a.

There is no proof of shared decision-making aids efficacy.

Most clinicians use decision-making tools.

Roughly 50 evidence-based decision aids are currently available on the Internet.

There is lack of access to shared decision-making aids.

ANS: A

There is proof of shared decision-making efficacy, however few clinicians and patients utilize existing decision-making tools such as patient decision aids. Even though over 500 evidence-based decision aids are currently available on the Internet, lack of access to these resources is a common complaint by those seeking to use them because they are scattered across dozes of websites and are not well advertised. 4. A new nurse practitioner plans to include patient activation as a major component of their practice. The nurse practitioner

understands that patient activation a.

can be defined as the knowledge the nurse practitioner has to motivate the patient.

is a static state.

includes patient progress and regress between levels of activation at various points in their life.

involves directing the patient where they need to go from the point you meet them forward.

ANS: C

To truly implement patient-centered evidence-based practices, the provider must meet the patient where they are at tailoring strategies that assess their strengths and challenges. Patient activation is defined as the knowledge, confidence, and skills that a patient possesses and is willing to use to make decisions about their health. Patient activation is a dynamic state meaning that a patient can progress and regress between levels of activation at various points in their life. 5. A nurse practitioner is reading a report which includes results of a Patient Activation Measure (PAM) for a patient who has

identified a goal to lower his cholesterol levels. When working with the patient who scored a 4 on the PAM, the nurse 1

practitioner should a.

be prepared to work with someone who has limited problem solving agility.

avoid stressful situations as this patient is more likely to become overwhelmed.

engage the patient in conversation regarding information to enhance their ability to advocate for their own health.

expect to encounter an individual who is more passive about their health.

ANS: C

Higher activated individuals (PAM), levels 3 and 4, are more likely to seek out and use information to be advocates of their own health. They are more likely to participate in wellness activities like regular exercise, maintain a healthy diet, and adhere to medical regimens because they consider themselves partners in their own health promotion. Individuals with lower ranking PAM scores (levels 1 and 2) are more likely to have a low confidence in their ability to self-manage and take a more passive approach to their health. PAM level 1 and 2 patients are less likely to embrace patient support resources, even when offered, and are more likely to be overwhelmed with stressful situations due to limited problem solving agility.

6. A nurse practitioner is working with a patient who scored a level 2 on PAM and has been identified as having low health

numeracy with normal health literacy. To enhance this patient’s understanding of correct insulin doses to maintain consistent blood sugars, it would be most effective for the nurse practitioner to a.

provide teaching in written text.

use infographics to break down numbers and display them as pictures.

incorporate graphs into patient teaching.

merge patient and ideal blood glucose recordings into a table for the patient to use.

ANS: B

Infographics that break down numbers and display them as pictures is one of the options to use when working with patients who have low health numeracy. Health literacy is defined as an individual’s ability to access, interpret, and understand qualitative data (no use of numbers) about their health. Health numeracy is an individual’s ability to access, interpret, and understand quantitative data (using numbers) about their health. Graphs and tables would most likely not assist this patient. 7. A nurse practitioner is advocating use of patient portals in the practice where he is employed. The nurse practitioner should focus

on the fact that patient portals have been designed to primarily a.

decrease the amount of time spent charting by staff.

keep information confidential.

facilitate patient flow in the practice.

promote patient engagement and self-care.

ANS: D

Patient portals are web-based platforms which compile various resources for patient engagement, such as decision-making aids, educational materials and communication applications which are typically connected to the electronic health record. They are designed to promote patient engagement and self-care. 8. One of the most cited contextual barrier against patient engagement is a.

lack of time for patient-provider interactions.

language barriers.

lack of EBP.

providers who wish to maintain control in health care decisions.

ANS: A

Lack of time for patient-provider interaction is cited repeatedly in the literature as a contextual barrier against patient engagement.

TRUE/FALSE 1. Health literacy is best described as an individual’s ability to access, interpret, and understand quantitative data.

ANS: F

Health literacy is an individual’s ability to access, interpret, and understand qualitative data. 2. A patient portal is a web-based platform which compiles various resources for patient engagement such as decision-making aids,

educational materials, and communication applications which are typically connected to the electronic health record. ANS: T

A patient portal is a web-based platform which compiles various resources for patient engagement such as decision-making aids, educational materials, and communication applications and is typically connected to the electronic health record and is used by their providers to provide health care data back to the patient. 3. The core of evidence-based practice is placing cost reduction at the center of all care decisions.

ANS: F

Putting the patient, whether individual, family or community, at the center of all care decisions is the core of evidence-based practice. 3

4. By keeping EBP patient-centric, the filter for interpreting and applying evidence in the contextual world in which that patient lives

to achieve health. ANS: T

Matching strategies for engagement that address individuals of all levels of health understanding and targeting how they want or believe they can be engaged in their care is necessary when behavior change or self-management is the goal. 5. By giving up their own centricity, providers can feel more professionally fulfilled by managing patient health instead of patient

flow. ANS: T

Patient engagement has been deemed a potential “blockbuster drug” and unfortunately has been underutilized. 6. Shared decision-making gained traction in the health care industry when shifts in payment model from a fee for service payment

structure to a pay for performance structure based on value occurred. ANS: T

In the emerging value-based delivery system there is increased focus on providing quality care at a low cost for populations.

7. A level 5 is considered to be the highest proficiency attainable for The Program for the International Assessment of Adult

Competencies (PIAAC). ANS: T

Participants are scored in the PIACC survey with “proficiency levels” from levels 1 to 5, with “below level 1” being the lowest level of problem solving/proficiency, and “level 4” as the highest proficiency. 8. Asking patients what they already know and understand to assess that understanding can allow patients and providers to enter into

conversations with a more-equal knowledge base. ANS: T

Asking patients what they already know and understand and using teach-back methods to assess that understanding can allow patients and providers to enter into conversations with a more-equal knowledge base breaking down individual barriers against patient engagement. 9. When patient-centered care is provided appropriately, the patient makes all decisions independently.

ANS: F

When patient-centered care is provided appropriately, patients are allowed to decide their own treatment course with the support of educated and invested health care providers.

Chapter 16: Evaluation of Evidence-Based Practice LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE 1. A team of researchers are evaluating the impact of implementing an EBP asking the clinical question, “Does use of an app to record

compliance with the prescribed therapeutic regimen impact re-admission rates for patients in heart failure?” The purpose of evaluation is to collect and analyze data from the practice setting to determine all but which one of the following? a.

Should the EBP be published?

Should the EBP be retained?

Should the EBP be modified?

Should the EBP be eliminated?

ANS: A

The purpose of evaluation is to collect and analyze data from the practice setting to determine if the EBPs should be retained, modified, or eliminated. 2. The key to effective evaluation is to demonstrate that the EBPs that are implemented is to a.

reduce cost.

decrease length of stay.

improve the quality of care and do not bring harm to the patient.

share results with others.

ANS: C

The key to effective evaluation is to demonstrate that the EBPs that are implemented improve the quality of care and do not bring harm to the patients. 3. Which of the following is the first step of evaluation for EBP? a.

Train the data collectors

Determine number of baseline and follow-up patents needed for each measure as appropriate

Determine methods and frequency of data collection

Identify process and outcome variables of interest

ANS: D

Steps of evaluation for evidence-based practice: (1) Identify processes and outcome variables of interest. (2) Determine methods and frequency of data collection. (3) Determine number of baseline and follow-up patients needed for each measure as appropriate. (4) Design data collection forms. (5) Establish content validity of data collection forms. (6) Train data collectors. (7) Assess interrater reliability of data collectors. (8) Collect data at specified intervals. (9) Provide staff regular feedback of measures to illustrate the progress in achieving the practice change. (10) Use data to assist staff in modifying or integrating the evidence-based practice change. (11) Provide final evaluation to staff and senior executives. (12) Write final evaluation report. 4. Which of the following statements is true? a.

EBP evaluation is a type of quality improvement.

A simultaneous comparison group is a component of EBP evaluation.

When evaluating EBP, be certain to review how the sample size was calculated.

Identification of how subjects were randomly assigned to groups is considered in the EBP evaluation.

ANS: A

EBP evaluation is a type of quality improvement. EBP evaluation is not conduct of research. Because EBP is not conduct of research, it is not necessary to have a simultaneous comparison group, calculate a sample size, or randomly select subjects. 5. Process measures are derived from which component of the PICO? a.

I 1

ANS: B

I stands for intervention, exposure, prognostic factor. Process of care measures are designed to evaluate staff’s use of EBPs as detailed in the local EBP standard. They measure whether the EBPs demonstrated to benefit patients are followed correctly. P stands for patient or problem. C stands for comparison and O stands for outcome. 6. Which of the following is an example of process measures? a.

Compliance with recommended infant vaccination series

Improvement of knowledge regarding appropriate use of car seats

Delivery of an asthma management brochure to parents of 2 to 6 year old children with asthma

Percent of infants presenting the emergency department who are suspected as suffering from abuse

ANS: C

Process of care measures are designed to evaluate staff’s use of the EBP as detailed in the local EBP standard. They measure whether the EBPs demonstrated to benefit patients are followed correctly. Delivery of an asthma management brochure to parents of 2 to 6 year old children with asthma is an example of a process measure. Outcome measures are those projected to change as a result of implementing the EBP. Compliance with recommended infant vaccination series, improvement of knowledge regarding appropriate use of car seats, and percent of infants presenting to the emergency department who are suspected as suffering from abuse are examples of outcome measures.

7. A group of health care providers are investigating whether a protocol for use of a particular anti-embolism stocking has an impact

on the number of pulmonary emboli occurrences in patients who undergo open colon resection for cancer. When evaluating the impact of implementing the EBP, which of the following is identified as an outcome measure? a.

Cost reduction

Percent of days the protocol for use of anti-embolism stocking was followed

Number of times patients ambulated per 24 hour period

Staff’s opinion if the process worked

ANS: A

Outcome measures are those projected to change as a result of implementing the EBP. Outcome measure may include not only patient outcomes, but also clinician outcomes such as improvement in staff knowledge, and fiscal outcomes such as cost reductions. The other options are not examples of outcome measures. 8. Which of the following is not an appropriate method to address fiscal outcomes? a.

Evaluating the potential cost savings of an EBP using selected outcome measures such as additional costs of care delivery associated with adverse events

Actual cost reduction with use of EBPs

Cost-benefit analysis evaluating the benefits of an EB intervention on outcomes in relation to the cost of delivering the EB intervention

Patient satisfaction with the EBP intervention

ANS: D

Patient satisfaction with the EBP intervention would be considered an outcome measure of the EBP intervention. All of the other options are appropriate methods to address fiscal outcomes of implementing EBPs. 9. When preparing a summary report of your EBP work for executive leaders and QI program members, the report should a.

be brief, about 2 to 3 pages.

include statistical process control charts in the body of the report.

avoid inclusion of names of individuals who worked on the project.

focus on the positive experiences during the project.

ANS: A

A summary report of your EBP work should be written for your executive leaders and QI program members. The report should be brief about 2 to 3 pages. Impact on quality of care can be appended to the report illustrating improvements using statistical process control charts. Lessons learned including both positive and negative experiences during the project as well as the names of the project team members and leader should be included. 10. Which statement by a new researcher regarding evaluating the impact of implementing evidence-based practices indicates that

further explanation is needed by the mentor? a.

Fiscal outcomes may include cost saving, cost reduction, and cost-benefit analysis.

Evaluation includes process measures only.

A common approach used for evaluation is a prospective pre-post-implementation design.

Process measures reflect staff’s use of EBPs and whether the EBPs demonstrated to benefit patients are followed correctly.

ANS: B

Evaluation must include both process and outcome measures. The other statements are true.

TRUE/FALSE

1. Evaluation is a structured approach to evaluate the impact of EBPs prior to implementation of the EBP in practice.

ANS: F

Evaluation is a structured approach to evaluating the impact of EBPs when implemented in practice. It includes collection and analysis of data from the practice setting to determine if the EBPs should be retained, modified, or eliminated. 3

2. Process measures evaluate staff’s use of the EBPs as detailed in the local EBP standard. They measure whether the EBPs

demonstrated to benefit patients are being followed. ANS: T

Process measures evaluate staff’s use of the EBPs as detailed in the local EBP standard. They measure whether the EBPs demonstrated to benefit patients are being followed. 3. Outcome measures are those projected to change as a result of implementing the EBPs. They are used to evaluate whether

implementation of the selected EBPs are resulting in improvements in health outcomes. ANS: T

Outcome measures are those projected to change as a result of implementing the EBPs. They are used to evaluate whether implementation of the selected EBPs are resulting in improvements in health outcomes. 4. Fiscal measures are estimated health care costs that may be impacted by implementing EBPs and include cost savings only.

ANS: F

Fiscal measures are estimated health care costs that may be impacted by implementing EBPs. Fiscal measures can address cost savings, cost reductions, and cost benefit.

5. When EBPs are implemented in the practice setting by multiple clinicians, the sample of subjects is most likely homogenous.

ANS: F

When an investigator is implementing a study protocol, the environment is controlled with a homogenous sample of subjects. When the EBPs are implemented in practice settings by multiple clinicians the patient population is heterogeneous. 6. A common approach used for evaluation is a prospective pre-post-implementation design.

ANS: T

A common approach used for evaluation is a prospective pre-post-implementation design. Using this format, baseline measures are collected prior to implementation to compare with the same measures at post-implementation. 7. Outcome measures do not reflect care processes but the actual results of care delivered on patient outcomes.

ANS: T

Outcome measures do not reflect care processes but the actual results of care delivered on patient outcomes. 8. Measuring outcomes alone without also measuring process of care is not recommended.

ANS: T

Improving outcomes requires improving care processes. 9. When outcomes do not improve the conclusion is that the EBPs are not working.

ANS: F

When outcomes do not improve there may be too much variability in implementation of the EBPs and thus the impact on outcomes may be limited. A measurement of both process and care outcomes is necessary to fully evaluate the EBP. 10. Individuals who have participated in implementing the EBP protocol should be excluded from implementing the changes in

practice to avoid bias. ANS: F

Individuals who have participated in implementing the protocol can be very helpful in evaluation by collecting data, providing timely feedback to staff, and assisting staff to overcome barriers encountered when implementing changes in practice.

Chapter 17: Dissemination LoBiondo-wood: Evidence-Based Practice for Nursing and Health Care Quality Improvement, 1st Edition

MULTIPLE CHOICE

1. Which of the following is a component of passive dissemination of EBP projects? a.

One-way communication

Real-time interaction

Bi-directional communication

Multiple conversations

ANS: A

Passive dissemination can be described as a one-way communication or top down process such as publishing, or posting information with the expectation that the intended audience will access and use the information. Active dissemination is characterized by real-time interaction with the intended audience to impart key messages or information, the dissemination is bi-directional communication and multiple conversations are used to discuss EBPs and rational for use. 2. When analyzing evaluation data from an EBP project intended to promote teamwork and interdisciplinary communication, it is

important to reflect on the intended audience to disseminate information and intervention materials by a.

sending the results to the appropriate national organization for approval.

tailor the report to the intended audience.

create a specific report for each discipline involved in the EBP.

share results with the chief executive officer of the organization who will determine if the EBP results are appropriate.

ANS: B

As EBP evaluation data is analyzed, it is important to identify the intended audience because objectives, methods, and venues for dissemination need to be tailored to the intended audience. It is not necessary to send the results to a national organization or organizational leader for approval. If the EBP project was intended to promote teamwork and interdisciplinary communication including members of multiple disciplines, one report should be developed to possibly impact interprofessional teamwork efforts. 3. When developing objectives for dissemination of EBP information to key senior leaders it is most important to a.

include information on how nursing procedures could be adapted to other areas.

discuss strategies for sustainability.

develop a detailed 10-page report.

illustrate improvements in both quality and cost.

ANS: D

Improvements in both quality and cost would be an appropriate objective for dissemination to key senior leaders. Staff nurses on the unit where the EBPs are implemented may include illustrations of how their contributions have improved process of care and outcomes including how nursing procedures could be adapted to other areas as well as a discussion of strategies for ongoing sustainability. Busy clinical leaders are more likely to read short 2-page executive summaries with details rather than a 10-page project report. 4. When preparing a poster to disseminate your work on an EBP, the nurse researcher should a.

include all specific details of the EBP project on the poster.

create a story board of key information.

avoid a sustained presence by the poster to allow individuals to read content alone to determine their own opinion of the work.

follow guidelines of Times New Roman 12 point font for all of the poster to make best use of space.

ANS: B

A poster presentation is a story board of key information. The design and layout of the poster is important to consider because it will draw people to read and possibly discuss you work therefore at least one member of the team should be available to discuss poster content. Presenting a poster is a social and interactive experience. 1

5. You are serving as a mentor for a school nurse practitioner who is preparing an oral presentation to disseminate findings from an

EBP focusing on use of social media to assist teens in smoking cessation. The audience is the National Association of School Nurses. Which statement by the School NP indicates the need for continued discussion of the oral presentation process? a.

I will time the talk so the audience has about 2 minutes to ask questions.

I plan to practice the presentation so I keep to the time limit.

I have developed a 25-word summary of my work and its impact that I plan to use as part of my talk.

I have omitted information about the complex methodology used for the EBP from the talk.

ANS: A

Oral presentations are always timed and generally last for about 15 to 20 minutes. The talk should be timed so the audience has 5 minutes to critique or ask questions about your work. The audience generally wants the speaker to get to the point. The talk should not be burdened with conceptually or methodically complex discussions. When preparing the talk, it is best to define the central message and do your best to develop a summary of your work and its impact that you can state in 25 words or less. You should practice the presentation being mindful of the time allocated for your talk.

6. Which one of the following statements regarding publishing to disseminate findings of EBPs should the nurse researcher take into

consideration? a.

Publishing findings of EBP generally is much less time consuming compared to preparing a poster.

Publishing your work in a peer-reviewed journal provides a high level of creditability to your work.

When publishing having grammar experts review and comment on the paper.

It will not be possible for others to replicate your work when publication is used to disseminate EBPs.

ANS: B

Publishing your work in a peer-reviewed journal provides a high level of credibility to your work and makes your work available to a larger audience than oral or poster presentations. Preparing your work for publication is time consuming and can be a tedious process. Having subject matter experts review and comment on your work is a cornerstone of the peer review process. Publication is an important vehicle to promote replication of your project. 7. Which of the following is a collection of electronic Web-based applications and technologies that facilitates interactive information

sharing, interoperability, user-centered design, and collaboration to promote active dissemination? a.

Twitter

Slideshare

Vimeo

Web 2.0

ANS: D

Web 2.0 is a collection of Web-based applications and technologies that facilitates interactive information sharing, interoperability, user-centered design, and collaboration. What differentiates Web 1.0 from Web 2.0 is the fact Web 1.0 is limited to passive dissemination of content whereas Web 2.0 and the related applications are a media space where creation and interaction of information content with each other occurs. Web 2.0 is considered to be active dissemination. Twitter is a popular online social network that enables users to send 140-character messages (tweets). Slide share is the world’s largest community for sharing online presentations and other documents including reports, videos, and infographics. Vimeo and YouTube are two popular video-sharing websites in which users can upload, share, and view videos. Vimel has become a major platform for dissemination of multimedia information. 8. Which of the following is not one of the five dimensions of RE-AIM framework? a.

Reach

Evaluation

Adoption

Maintenance

ANS: B

The RE-AIM framework focuses on five dimensions: reach, effectiveness, adoption, implementation, and maintenance

TRUE/FALSE

1. An example of passive dissemination of EBP projects is publishing.

ANS: T

Passive dissemination is a one-way communication or top down process such as publishing, or posting information with the expectation that the intended audience will access and use the information. 2. Bi-directional communication is used in the active dissemination process

ANS: T

Active dissemination is real-time interaction with the intended audience to impart key messages of information, the dissemination is bi-directional communication and multiple conversations are used to discuss EBPs and rationale for use. 3. Implementation fidelity occurs when a new practice becomes embedded into daily workflow. 3

ANS: F

Implementation fidelity can be described as measurement of the degree to which participants carry out the EBPs as intended. Sustainability occurs when a new practice becomes embedded into daily workflow. 4. When disseminating methods and results of an EBP project the researcher should include methods for implementation, the impact

on care delivery, and both process and outcomes. ANS: T

Dissemination included spreading the EBPs methods for implementation, the impact on care delivery including both process and outcomes. 5. A poster presentation is a story board of key information.

ANS: T

A poster presentation is a story board of key information. 6. The hardest part of doing an oral presentation is anticipating your audience and tailoring your presentation to that audience.

ANS: T

The hardest part of doing an oral presentation is anticipating your audience and tailoring your presentation to that audience.

7. Having subject matter experts review and comment on your work is a cornerstone of the peer review process of publication.

ANS: T

With publication, having subject matter experts review and comment on your work is a cornerstone of the peer review process. 8. Health care workers are generally not in favor of using Web 2.0 tools such as Wikis for research dissemination.

ANS: F

Evidence is beginning to appear in the literature that health care workers are in favor of using Web 2.0 tools such as Wikis as knowledge translation tools that could help health professionals implement best practices in trauma care.