Competencies:
This course provides guidance to help you demonstrate the following :
Competency 744.3.1: Information Management
The graduate evaluates information management systems that support timely, high quality, patient-centered care.
Competency 744.3.2: Leadership in Nursing Informatics
The graduate integrates knowledge of nursing initiatives, professional organizations, and leadership into strategies for enhancing nursing informatics.
Competency 744.3.3: Health Information Systems
The graduates distinguishes between the critical and useful electronic data needed for effective decision support (clinical, financial and administrative outcomes) to provide high quality and efficient care.
Competency 744.3.4: Information Security
The graduate evaluates the privacy and security of data within healthcare organizations.
ensure quality patient outcomes.
Competency 744.3.5: Current and Future Technologies
The graduate evaluates the implications of current and emerging technologies for practice, research,education, and administration.
Preparing for Success
The information in this section is provided to detail the resources available for you to use as you complete this course.
Learning Resources
The learning resources listed in this section are required to complete the activities in this course. For many resources, WGU has provided automatic access through the course. However, you may need to manually enroll in or independently acquire other resources. Read the full instructions provided to ensure that you have access to all of your resources in a timely manner.
Automatically Enrolled Resources
You can access the learning resources listed in this section by clicking on the links provided throughout the course. You may be prompted to log in to the WGU student portal to access the resources.
Tan, J. and Payton, F.C. (2009) Adaptive Health Management Information System, 3d edition. ISBN 13978076375691-8
Mastrian, K. G., McGonigle, D. (2017). Informatics for Health Professionals. Burlington, MA: Jones & Bartlett Learning.ISBN-13 is: 9781284102635
Pacing Guide
The average student should be able to complete one Unit per week.
Topics and Pacing
Unit 1: Introduction and Getting Started
· Module 1:Introduction and Getting Started
Unit 2: Information Management
· Module 2:Information Management
Unit 3: Health Information Systems
· Module 3: Health Information Systems
Unit 4: Information Security
· Module 4: Information Security
Unit 5: Current and Future Technologies
· Module 5: Current and Future Technologies
Unit 6: Leadership in Nursing Informatics
· Module 6: Leadership in Nursing Informatics
Unit 7: Final Performance Assessments
Please continue to the next section to begin your course work.
Working in environments of increasingly complex clinical care and contending with the management of large volumes of information, nurses need to avail themselves of the technological tools that can support quality practice that is optimally safe, informed, and knowledge-based. Despite the availability of the latest hi-tech tools, unless the information gathered is analyzed and used appropriately, it is of little value; in fact it may have a negative impact on patient care. Equally important to the gathering of the data is an attention to the quality of that data.
The quality of the data itself is closely tied to quality indicators. The quality indicators themselves are not an adequate benchmark if the data or information used to make informed decisions is flawed. For example, if only half of the prescription errors occurring at a health organization are actually reported, then it could be inaccurately concluded that there is no problem.
What exactly is quality information? It is information that is accurate and correct. There are specific characteristics that can be used to evaluate the quality of a piece of information. These include:
Relevance
Quality information is relevant. This means that the information being used must apply directly to the reason that it is needed.
For instance, if information is needed about a patient’s health history, in order to better assess and diagnose the patient, it is relevant to collect information on the patient’s previous hospitalizations. It would not, however, be relevant to use public health data to analyze a patient’s health history.
Timely
Another characteristic of quality information is that it is timely. When there is a lag in information, it may no longer be of use or properly serve its purpose. Information must be efficient and must be provided in a timely manner so that nurses can utilize it in their practice.
For instance, when attending to a patient with a clinical emergency, data and information, such as drug allergies or special medical conditions, are needed urgently. The faster the information is provided, the more efficient and effective the clinical services will be for the patient. However, if the information arrives too slowly, the patient could already suffer consequences of the clinical emergency.
Thorough
Quality information is thorough, which means that the information must be complete. Information that is not thorough might contain errors or lapses of information.
Consider the example of a patient who is allergic to latex. The nurse who filed the admission paperwork neglects to include the allergy warning on the medical record. Therefore, the next nurse who works with the patient is unaware of the patient’s allergy to latex, and uses latex gloves to provide clinical care. This is an example of incomplete, or non-thorough information, because an important fact was left out, which negatively impacts quality and safety as well as steps in the nursing process.
Objective
Quality information is objective. This means that information must be as close to the facts as possible and not based on individual opinions. If information becomes subjective, or based only on personal opinions or feelings of the nurse, errors can occur.
An example of a subjective report is “Patient needs more pain medication because she looks awful.” This subjective statement does not provide any facts or details. Instead, an example of an objective report is “Patient is shivering and looks pale. She continues to rub her legs, but the swelling has not gone down yet. Recommend more pain medication.” This statement is objective because it provides facts and details without blurring them with personal interpretations and demonstrates how objective information is used in assessing, diagnosing, and determining a nursing care plan.
Transparent
Transparency is another characteristic of quality information. Transparency, in this context, means that information is accessible and available. Information must be transparent so that anyone can use and apply the information in practice. If information is not transparent, others are unable to access it or put it to use.
For instance, if doctors are the only healthcare providers who can access patient information, the nurses on the team would not know vital information about the patient, such as the medications that the patient is taking, or whether the patient has any pre-existing health conditions. Not having the necessary information inhibits providing quality care and each step in the nursing process.
Reproducible
Information must be reproducible in order for it to be considered quality information. Reproducible information can be created again and again, which ensures validity and accuracy.
For example, if a nurse generates a report on the hospital’s average length of stay, but another nurse does not believe the results of the report, the nurse can check the numbers again and, if the information is reproducible, will find that the report still reflects the same information.
Verifiable
Quality information is able to be verified so that nurses can see that the information is accurate and error-free. Verifiable means that information is able to be checked for facts.
An example of verifiable information is when a nurse manager shares with the nursing team new information about medication side effects that was just issued by the Centers for Disease Control and Prevention (CDC). To verify this information, the other nurses decide to check the claims themselves by looking on the CDC’s website. Sure enough, the facts are there, and the information is therefore verifiable. Consider how this applies, then, to the nursing process. Imagine you are treating a patient that presents with some of the newly discovered side effects. Verifiable information is critical as nurses diagnose and develop care plans for patients. If you had not been able to verify the information, you may incorrectly assess or misdiagnose the patient’s health problem.
It is the integrity and quality of data and information that make it useful. Data integrity can be compromised through human errors, viruses, hardware failures or crashes, transmission errors, or hackers entering the system. Information management systems help to decrease these errors by putting safeguards in place such as automatic file backups so data is not lost, error detection for transmissions, and data entry error alerts (i.e. a field such as patient name was not completed). Only when high quality data is processed into information can it create meaning to inform patient care, the nursing process, and facilitate timely, high quality, patient-centered care.
The National Database of Nursing Quality Indicators (NDNQI) examines nursing’s impact on patient outcomes, especially when looking at nursing staff ratios to patient outcomes.
Quality indicators use data that is readily available in healthcare organizations to determine systemic problems that could be improved. In addition, they provide a guideline by which an organization can not only measure, but compare itself to other healthcare organizations. This ability to measure performance allows healthcare organizations to improve the quality of care delivered, which then leads to better patient outcomes.
During rounds, Charles encounters a rare pulmonary condition he has never personally seen and only vaguely remembers hearing about in respiratory therapy school. He takes a few moments to prepare himself by searching the Internet. That evening, he does even more research so that he can assess and treat the patient safely. He searches clinical databases online and his own school textbooks. Most of the information seems consistent, yet some factors vary. Charles wants to provide the safest and highest quality of patient care. He wonders which resources are best, which are the most trusted, and which are the most accurate.
The Foundation of Knowledge model suggests that the most important aspect of information discovery, retrieval, and delivery is the ability to acquire, process, generate, and disseminate knowledge in ways that help those managing the knowledge reevaluate and rethink the way they understand and use what they know and have learned. These goals closely reflect the Information Literacy Competency Standards for Higher Education, published by the American Library Association (ALA) in 2003 in response to changing perceptions of how information is created, evaluated, and used.
According to the ALA (2000), an information-literate individual is able to do the following:
▪ Determine the extent of information needed
▪ Access the needed information effectively and efficiently
▪ Evaluate information and its sources critically
▪ Incorporate selected information into one’s knowledge base
▪ Use information effectively to accomplish a specific purpose
▪ Understand the economic, legal, and social issues surrounding the use of information and access and use information ethically and legally (para. 8)
In addition, new challenges arise for individuals seeking to understand and evaluate information because information is available through multiple media (graphical, aural, and textual). The sheer quantity of information does not by itself create a more informed citizenry without complementary abilities to use this information effectively. Most significantly, information literacy forms the basis for lifelong learning, serving as a commonality among all learning environments, disciplines, and levels of education (Association of College and Research Libraries [ACRL], 2000).
This chapter introduces the concepts of information literacy, fair use of information, translational research concepts, and their role in promoting evidence-based practice. Information management technologies are an integral part of evidence-based practice, and it is important for all health care disciplines to appreciate the contribution of this aspect of health informatics to patient care.
Information literacy is an intellectual framework for finding, understanding, evaluating, and using information. These activities are accomplished in part through fluency with information technology and sound investigative methods but most importantly through critical reasoning and discernment. The ACRL (2000) has suggested that “information literacy initiates, sustains, and extends lifelong learning through abilities that may use technologies but are ultimately independent of them” (p. 5).
The ability to recognize the need for a specific kind of information and then locate, evaluate, and effectively use that information (ALA, 1989) within the health informatics paradigm will catapult some health care professionals ahead of other health care professionals in providing evidence-based care. Traditional approaches to care that adhere to the “we have always done it this way” adage are no longer good enough. Our patients deserve care that utilizes the best available research and practice evidence.
In an environment characterized by rapid technological change, coupled with an overwhelming proliferation of information sources, health care professionals face an enormous number of options when choosing how and from where to acquire information for their academic studies, clinical situations, and research. Because information is available through so many venues—libraries, special interest organizations, media, community resources, and the Internet—in increasingly unfiltered formats, health care practitioners must inevitably question the authenticity, validity, and reliability of information (ACRL, 2000).
Often, the retrieval of reliable research and information may seem to be a daunting task in light of the seemingly ubiquitous amount of information found on the Web. Focusing on specific information venues not only aids this search but also assists in negotiating the endless maze of resources, allowing a professional to find the best and most accurate information efficiently.
Professional databases represent a source of online information that is generally invisible to all Internet users except those with professional or academic affiliations, such as faculty, staff, and students. These databases, which range from specific to general, act as collection points by aggregating information, such as abstracts and articles from many different journals; two such databases include the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE . CINAHL, for example, specifically includes information from all aspects of allied health, nursing, alternative medicine, and community medicine. The MEDLINE database contains more than 10 million records and is maintained and produced by the National Library of Medicine. Other databases, such as PsycInfo from the American Psychological Association and the Educational Resources Information Center (ERIC) database, may also benefit health care professionals. Still others are more specific by discipline, such as OTseeker (specific to occupational therapy), PEDro (specific to physical therapy), and speechBITE (for speech therapists). Many databases also offer full-text capabilities, meaning that entire articles are available online. The articles and abstracts contained within these databases have already withstood the rigors of publication in professional journals and, therefore, are considered viable and authentic peer-reviewed sources.
Libraries with subscriptions to databases often employ library professionals who are able to help patrons sift through the vast amounts of available electronic information; using the expert research capabilities of a health science librarian at one’s local university is the best way to learn how to conduct database searches that yield the most efficient and useful results. Also useful are websites that provide tutorials on best searching practices specifically for medically oriented databases, such as the tutorials provided by EBSCO support to search the CINAHL database (http://support.epnet.com/training/flash_videos/cinahl_basic/cinahl_basic.html and http://support.epnet.com/training/flash_videos/cinahl_advanced/cinahl_advanced.html).
Search engines allow users to surf the Web and find information on nearly anything, although many involved in conducting scholarly research steer clear of search engines because of the vast amounts of unsubstantiated information they are likely to uncover. Because no legitimacy needs to be provided for any information that appears on the Web, an author can make claims, substantiated or not, and still use the Web as a publishing venue. Despite the pitfalls associated with search engines in general, they can yield a bounty of useful information when used with discretion.
Different search engines will produce different results when used for the same research. For example, one popular search engine ranks its results by number of hits that a page or site has received. Whereas the most popular research results are likely to be relevant, the order in which results appear does not indicate quality or viability of the source.
Different Web address (domain) suffixes (.com, .edu, .org, .gov, and so forth) indicate who is responsible for creating the website. Although an .edu site is hosted by an educational institution and for that reason may seem legitimate, consider that it could also belong to a student stating personal opinion, gossip, or guesswork. In contrast, .gov sites are maintained by the government and nearly always have professional contact information. Web hosts develop new domain suffixes constantly, so although looking at the suffix can be useful, it should not be the sole deciding factor when choosing to trust information.
One should never blindly trust information found on a webpage. When possible, check the date of the most recent update (How old is the page?), contact information (Is a bibliography or list of sources provided?), links to external sources (Do they seem relevant?), and previous attained knowledge from other reputable sources (Is the information too unbelievable?).
Fees and information retrieval charges should be approached with skepticism. Private companies do offer information aggregation services for a fee. In these cases, users pay a flat monthly fee for access to collections of articles in a particular field. What users (especially those affiliated with an academic institution) may not realize is that they are likely to have free access to the same, if not more complete, information through their institution’s library system.
Some legitimate databases and traditional newspapers that maintain a Web presence do provide access for a small fee, but just as many others simply ask users to register to see articles for free. Many students and professionals affiliated with a university may find that their university library has already purchased access for those affiliated with the university—students, faculty, and staff.
Nearly all higher education institutions have placed their library catalogs online. Although this is an obvious convenience for many students, some health care professionals unaccustomed to working completely online may be intimidated by an e-catalog. Library professionals at the tiniest university and the busiest community college are available to demonstrate how to navigate a basic search of their library’s catalog. Asking for assistance in learning how to access the vast assortment of journals, books, databases, and other resources available at one’s college library is an excellent idea. Students in health care programs at larger universities will likely find free classes that specifically teach users how to navigate and use the online catalog. If smaller colleges and universities do not offer these services, one should take advantage of the library’s online tutorials, help pages, frequently-asked-questions pages, and online reference service (if available). Local public libraries often have subscriptions to popular databases and offer free classes on searching techniques to patrons, providing yet another free access point to the best information for one’s research needs. Making full use of available library resources serves to strengthen information literacy skills, enabling learners to master content and extend their investigations, become more self-directed, and assume greater control over their own learning (ACRL, 2000).
Copyright laws in the world of technology are notoriously misunderstood. The same copyright laws that cover physical books, artwork, and other creative material apply in the digital world. Have you ever given a friend a CD that contains a computer game or some other type of software that you paid for and registered? Have you ever downloaded a song from the Internet without paying for it? Have you ever copied a section of online content from a reference site and used that content as if it were your own? Have you ever copied a picture from the Internet without asking permission from the photographer who took the picture? Have you ever copied and pasted information about a disease or drug from a website and then printed out the information to give to a patient or family member? These are all examples of the type of copyright infringements enabled by technology that occur almost without thought.
The value of creative material—whether it is written content, a song, a painting, or some other type of creative work—lies not in the physical medium on which it is stored but rather in the intangibles of creativity, skills, and labor that went into creating that item. The person who created the material should be properly credited and possibly reimbursed for the use of the material. How would musicians be reimbursed for their music if everyone just downloaded their songs illegally from the Internet? Imagine that you created a game to teach patients with type 1 diabetes how to manage their diet and other dieticians copied and distributed that game without getting your permission to do so. How would you feel?
Almost all software, music CDs, and movie DVDs come with restrictions on how and why copies can be made. The license included with the software clarifies exactly which restrictions are applicable. The most common type of software license is a “shrink wrap” license, meaning that as soon as the user removes the shrink wrap from the CD or DVD case, he or she has agreed to the license restriction. Most computer software developers allow for a backup copy of the software to be made without restriction. If the hard drive fails on the user’s computer, the software can usually be reinstalled through this backup copy. Some software companies even allow the purchaser of a software package to transfer it to a new user. In this case, the software typically must be uninstalled from the original owner’s computer before the new owner is free to install the software on his or her computer. Most of these restrictions depend on the honesty of the user in reading and following the licensing agreement. As a result of widespread abuses, however, the music and film industries commonly include hardware security features in their products that block users from making a working copy of a music CD or movie DVD.
The bottom line: Copyright laws also apply to the digital world, and copyright violations can lead to prosecution. Advances in technology have made the sharing of information easy and extremely fast. A scanner can convert any document to digital form instantly, and that document can then be shared with people anywhere in the world. Nevertheless, the person who originally created that document has the right to approve of the sharing of their work. Carefully read the fine print of any software purchased and be sure to clarify any questions regarding how that software can be copied. Avoid downloading music illegally from the Internet, and do not use information from the Internet without permission to do so or without citing the reference appropriately. Health care organizations that allow access to the Internet from a network computer should ensure that users are well aware of and compliant with all copyright and fair use principles.
Evidence-based practice, translational research, and research utilization are all terms that have been used to describe the application of evidential knowledge to clinical practice. The following paragraphs explore the definitions of each term. Although these terms are related, they have slightly different meanings and applications.
Evidence-based practice (EBP), developed originally for its application to medicine, is defined by Sackett, Rosenberg, Gray, Haynes, and Richardson (1996) as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (p. 71). The “best evidence” in this context refers to more than just research. Goode and Piedalue (1999) state that EBP should be combined with other knowledge sources and “involves the synthesis of knowledge from research, retrospective or concurrent chart review, quality improvement and risk data, international, national, and local standards, infection control data, pathophysiology, cost effectiveness analysis, benchmarking data, patient preferences, and clinical expertise” (p. 15). EBP starts with a clinical question to resolve a clinical problem. For example, published research studies are used in health care quality initiatives as the evidence behind the development of practice algorithms designed to decrease practice variability, increase patient safety, improve patient outcomes, and eliminate unnecessary costs. Use of EBP promotes the use of clinical judgment and knowledge, with procedures and protocols being linked to scientific evidence rather than based on what is customary practice or opinion (Stevens, 2004).
Research utilization is the use of findings from one or more research studies in a practical application unrelated to the original study (Polit & Beck, 2008, p. 29) resulting in the generation of new knowledge. Stetler (2001) defines research utilization as the “process of transforming research knowledge into practice” (p. 274). Research utilization can be self-limiting if research is inconsistent or not enough research is available to develop a consensus regarding the answer to the clinical question (Kirchhoff, 2004).
Translational research (science) describes the methods used in translating medical, biomedical, informatics, and health care research into clinical interventions. Woolf (2008) describes translational research in two ways:
▪ T1: the transfer of clinical research to its first testing on humans
▪ T2: the transfer of clinical research to an everyday clinical practice setting
Difficulties in translating research to the T2 setting exist when research applications do not fit well within the clinical context or practical considerations within the organization constrain the application in a clinical setting. Translational research is complicated by the follow-up analysis, practice, and policy changes that occur when adopting research into practice; consequently, available evidence-based health care practices are often not fully incorporated into daily care (Titler, 2004, 2010). Organizational culture influences the changes made to a clinical application and establishes the groundwork and the support for change-making activities (Titler, 2004). The study of ways to promote the adoption of evidence in the health care context is called “translation science” (Titler, 2010).
Research results are crucial to furthering EBP. The concept of using randomized controlled trials (RCTs) and systematic reviews as the gold standard against which one should evaluate the validity and effectiveness of a clinical intervention was introduced in 1972 by Archie Cochrane (1972), a scientist and a physician. Cochrane’s experiences as a prisoner of war and medical officer while interning during World War II led to his belief that not all medical interventions were needed and that some caused more harm than good. Cochrane viewed the randomized clinical trial as a means of validating clinical interventions and limiting the interventions to those that were scientifically based, effective, and necessary (Dickersin & Manheimer, 1998).
Cochrane’s colleague, Iain Chalmers, began compiling a comprehensive clinical trials registry of 3,500 clinical trial results in the field of perinatal medicine. In 1988, after being published in print 3 years earlier, the registry became available electronically. Chalmers’s methods for compiling the trials databases became a model for future registry assembly. Eventually, the National Health Service in the United Kingdom, recognizing the value of and need for systemic reviews for all of health care, developed the Cochrane Center. The Cochrane Collaboration (2004) was initiated in 1993 and expanded internationally to maintain systematic reviews in all areas of health care (Dickersin & Manheimer, 1998). Many universities subscribe to the Cochrane Collaboration database, making this information easily accessible to students, faculty, and health care professionals who work for university hospital systems.
The RCT is considered the most reliable source of evidence. Yet RCTs are not always possible or available; consequently, health care professionals must use critical analysis to base their clinical decision making on the best available evidence (Baumann, 2010). The updated Stetler model of research utilization (Stetler, 2001) identifies internal and external forms of evidence. External evidence originates from research and national experts, whereas internal forms of evidence originate from nontraditional sources, such as clinical experience and quality improvement data.
Evidence includes standards of practice, codes of ethics, philosophies of practice, autobiographic stories, aesthetic criticism, works of art, qualitative studies, and patient and clinical knowledge (Melnyk, Fineout-Overholt, Stone, & Ackerman, 2000). French (2002) summarizes evidence as “truth, knowledge (including tacit, expert opinion and experiential), primary research findings, meta-analyses and systematic reviews” (p. 254). Health care professionals may additionally draw on evidence from the context of care , such as audit and performance data, the culture of the organization, social and professional networks, discussion with stakeholders, and local or national policy (Rycroft-Malone et al., 2004, p. 86).
To use evidence in practice, the weight of the research, also called research validity , must be determined. Evidence hierarchies have been defined to grade and assign value to the information source. For example, an evidential hierarchy developed by Stetler et al. (1998) prioritizes evidence into six categories:
1. Meta-analysis
2. Individual experimental studies
3. Quasi-experimental studies
4. Nonexperimental studies
5. Program evaluations, such as quality improvement projects
6. Opinions of experts
The hierarchy identifies meta-analysis as the best-quality evidence because it uses multiple individual research studies to reach a consensus. It is interesting to note that opinions of experts are considered the least significant in this hierarchy, yet health care professionals most often seek the opinion of a more experienced colleague or peer when seeking information regarding patient care (Pravikoff, Tanner, & Pierce, 2005).
Qualitative research allows one to understand the way in which the intervention is experienced by the researcher and the participant and the value of the interventions to both parties (O’Neill, Jinks, & Ong, 2007). Qualitative research is not always considered in EBP because methods for synthesizing the evidence do not currently exist. The Cochrane Qualitative Research Methods Group (CQRMG) is developing search, appraisal, and synthesis methodologies for qualitative research (Joanna Briggs Institute, n.d.).
The time between research dissemination and clinical translation may be significant, and this delay may adversely affect patient outcomes. Bridging the gap between research and practice requires an understanding of the key concepts and barriers, access to research findings, access to clinical mentors for research understanding, a reinforcing culture, and a desire on the part of the clinician to implement best practices (Melnyk, 2005; Melnyk, Fineout-Overholt, Stetler, & Allen, 2005). In the Iowa model of EBP, research and other evidential sources are adopted directly in the practice setting with the goal of developing a standard of care (Titler, 2007). Additionally, the groundwork required to create a conceptual framework supportive of an EBP includes workplace culture change and support of the change through leadership (Stetler et al., 1998). Beliefs and attitudes, involvement in research activities, information seeking, professional characteristics, education, and other socioeconomic factors are potential determinants of research utilization (Estabrooks, Floyd, Scott-Findlay, O’Leary, & Gushta, 2003); however, meta-analysis points out that too much original research and not enough repetition of previous studies fails to advance the knowledge base.
Developing countries are often constrained economically from accessing research sources. Such organizations as the Cochrane Collaboration provide free reviews to fill this void. Even so, knowledge dissemination strategies and education are required to take advantage of these resources (Cochrane Collaboration, 2004).
Barriers to the application of EBP include lack of time, lack of access to libraries within a facility, lack of technology confidence, lack of knowledge on how to search for information, lack of value assigned to using research in practice (Pravikoff et al., 2005), inadequate EBP knowledge and skills, lack of mentors in EBP, inadequate support and resources from administration, and insufficient time (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2009). McKnight (2006) noted that nurses on one unit felt constrained by time and ethically obligated to provide patient care rather than spend time looking up evidence-based references. Nurses may also see the job of interpreting research as too complex or see the organizational culture as a barrier to implementation of EBP (McCaughan, Thompson, Cullum, Sheldon, & Thompson, 2002). Some of these same attitudes toward EBP may be echoed by other health care professionals. Heiwe et al. (2011) surveyed occupational therapists, physical therapists, and dieticians to uncover attitudes, beliefs, knowledge, and practice related to EBP. They found generally positive attitudes toward using evidence to support clinical practice and confidence among these clinicians in their ability to interpret and apply evidence in practice. Results also indicated concern by professionals that EBP guidelines may not adequately reflect patient preferences and that time was the major barrier that interfered with EBP use.
Yet, Melnynk et al. (2009) noted that a number of factors also facilitate the use of EBP. These driving forces include knowledge and skills in EBP, having a conviction that there is a value to using evidence in practices, and practicing in a supportive culture with tools available to sustain evidence-based care, including access to computers and databases, evidence-based content at the point of care, and the presence of EBP mentors. Similarly, a pre–post study of allied health professionals demonstrated that a structured journal club was an effective tool among some professionals for improving understanding of EBP and attitudes toward using evidence in clinical practice (Lizarondo, Grimmer-Somers, Kumar, & Crockett, 2012).
Computers are used in all areas of research: (1) literature search databases, such as CINAHL; (2) online literature reference lists, such as RefWorks; (3) data capture, collection, and coding; (4) data analysis; (5) data modeling; (6) meta-analysis; (7) qualitative analysis; and (8) dissemination of results (e.g., via e-mail or Internet website) (Saba & McCormick, 2006). The context for health informatics has expanded to support dramatic changes in the way science is accomplished. Information need and the collaborative component of interdisciplinary research rely heavily on technology and informatics. Technologies, such as social networking (Web 2.0), may also improve collaboration. The use of technology and informatics in facilitating interdisciplinary and translational research is a key architectural component of the National Institutes of Health’s reengineering of the clinical research enterprise as part of its road map initiative for medical research (National Institutes of Health, 2009).
An informatics infrastructure is critical to EBP. Bakken, Stone, and Larson (2008) discuss expanding the context of informatics to genomic health care, shifting research paradigms, and social web technologies. Ensuring the global collaborative nature of health care research for 2010–2018 requires an expansion of the research agenda to user information needs, data management, information support for health care professionals and patients, practice-based knowledge generation, and design evaluation methodologies. Giuse et al. (2005) describe the evolving role of the clinical informationist as being a partner on the health care team who provides timely clinical evidence for the clinical work flow. The National Institutes of Health provides awards under its Clinical and Translational Science Award (CTSA) program to accelerate the transfer of research to the clinical setting (National Institutes of Health, 2009). With the goal of promoting the use of research findings and tool use based on these findings, the Agency for Healthcare Research and Quality (AHRQ) became an active participant in pushing evidence forward into practice. The AHRQ is a government-sponsored organization with the mission of reducing patients’ risk of harm, decreasing health care costs, and improving patient outcomes through the promotion of research and technology applications focused on EBP. In 1999, AHRQ implemented its Translating Research into Practice Initiative (TRIP) to generate knowledge about evidence-based care (AHRQ, 2001). In the second Translating Research into Practice Initiative (TRIP-II), the focus shifted to improving health care for underserved populations and using information technology to shape translational research and health policy. AHRQ, in partnership with the American Medical Association and the American Association of Health Plans, developed the National Guideline Clearinghouse (NGC). NGC is a comprehensive database of evidentially based clinical practice guidelines and related documents that are regularly published through the NGC electronic mailing list and are available on the NGC website (NGC, 2015). The NGC website allows users to browse for the clinical guidelines, view abstracts and full-text links, download full-text clinical guidelines to personal digital assistant (PDA) devices and smartphones, obtain technical reports, and compare guidelines. For example, a search (August 22, 2015) using “dental hygiene” as the key words yielded links to 52 guidelines—one of which was titled “Guideline on oral health care for the pregnant adolescent, created in 2007 and revised in 2012 (NGC, 2015). PubMed4Hh (PubMed for handheld devices) is a powerful, free application for smartphones that provides access to the National Library of Medicine and supports PICO (Population, Intervention, Comparison, Outcome) searches, clinical queries, and multi-language searches with links to consensus abstracts. Several universities have developed comprehensive research guides to assist health care professionals in finding evidence to support practice. One of the more comprehensive guides for allied health professionals is provided by Eastern Michigan University (http://guides.emich.edu/c.php?g=217258&p=1435210). Check your own library system as well for EBP resources.
In addition, a growing number of printed and electronic resources are available to assist in creating guidelines and offering information about EBP. A selection of existing websites is shown in Table 17-1 .
TABLE 17-1 THE ROLE OF INFORMATICS: ONLINE EVIDENCE-BASED RESOURCES
Several models have been developed to guide organizations into translating research into practice. Brief descriptions of these models are provided in Table 17-2 . As an example, Titler (2007) identifies the steps in the Iowa model for translating research into practice as (1) identifying the problem, issue, or topic in professional practice; (2) research and critique of related evidence; (3) adaptation of the evidence to practice; (4) implementation of the EBP; and (5) evaluation of patient outcomes and care practices. Careful analysis and discussion of the research or other forms of evidence in this scenario may reveal that given the context, implementation may not be practical. Following implementation, results must be monitored to determine whether the application works for the context. Thoughtful discussion of the findings will help the clinical team determine if further research is warranted or if further change is needed.
Information technology is important in synthesizing the research regardless of the model. Bakken (2001) recommends (1) standardized nomenclature required for the electronic health record (standardized terminologies and structures), (2) digital sources of evidence, (3) standards that facilitate healthcare data exchange among heterogeneous systems, (4) informatics processes that support the acquisition and application of evidence to a specific clinical situation, and (5) informatics competencies (p. 1999). Bakken’s recommendations encourage the development of an infrastructure that creates a database of experiential clinical evidence.
TABLE 17-2 COMPARISON OF MODEL APPROACHES TO EVIDENCE-BASED PRACTICE
Systematic reviews combine results from multiple primary investigations to obtain consensus on a specific area of research. They are much more robust than a simple review of the literature that one might use to define a topic before writing a paper. The goal of a systematic review is to find and appraise all relevant literature on a topic. Studies are discarded from the review if they are not considered sound, thereby creating a reliable end result. The strength of the systematic review is its ability to corroborate findings and reach consensus. Systematic reviews show the need for more research by revealing the areas where quantitative results may be lacking or minimal. Bias may occur if the selected studies are inadequate, if all sources of evidence are not investigated, or if the publications selected are not adequately diverse (Lipp, 2005).
Meta-analysis, a more vigorous form of systematic review, uses statistical methods to combine the results of several studies (Cook, Mulrow, & Haynes, 1997). Quantitative studies are typically used. According to Glass (1976), meta-analysis is the statistical analysis of a large collection of analysis results from individual studies for the purpose of integrating the findings (p. 3). Both systematic reviews and meta-analyses require the researcher to use critical thinking in order to effectively combine and interpret the findings.
Kraft (2006) describes the documentation search strategy for meta-analysis as beginning with the identification of the studies through a search of bibliographic databases, identification of meta-analysis articles that match the search criteria, elimination of those articles that do not match the search criteria, review of the reference lists in the meta-analysis for other articles that may relate to the topic, and review of each article for quality and content. Additional sources should include unpublished works, such as conferences and dissertation abstracts, with the goal of obtaining as many relevant articles as possible. Gregson, Meal, and Avis (2002) identify the steps of a meta-analysis as (1) defining the problem, followed by protocol generation; (2) establishing study eligibility criteria, followed by literature search; (3) identifying the heterogeneity of results of studies; (4) standardizing the data and statistically combining the results; and (5) conducting sensitivity testing to determine whether the combined results are the same. The often-cited criticism of meta-analysis is that emphasis is on quantitative studies (those using numeric data), not qualitative studies (those using words and descriptions as data). Additionally, the analysis is only as good as the studies used (Gregson et al., 2002). Collection and dissemination of these meta-analysis and systematic reviews are available in paper and on the Internet, although many such databases require a subscription.
The term “open access” refers to a worldwide movement to make a library of knowledge available to anyone with Internet access. The Open Access Initiative came about in response to the tremendous cost of research library access. Libraries pay large fees for journal subscriptions, and the richness of library references is limited to what the budget allows. The cost of keeping current with research has caused library subscriptions to decline (Yiotis, 2005). Open access adds to the controversy, with some journals charging authors for publication of their work, which in itself may provide a financial barrier to publication in this form.
According to Suber (2004), open access refers to digital literature that is available to anyone with Internet access free of charge. There are two vehicles for open access: archives and journals. Open-access journals are generally peer reviewed and freely available. The publishers of open-access journals do not charge the reader but rather obtain funds for publishing elsewhere. Open-access journals may charge the author or depend on other forms of funding, such as donations, grants, and advertising, to publish.
Titler (2007) indicates that future priorities should include development of theoretical formulations to guide research and systematic reviews so that they may be grouped by organizational context (e.g., primary care, outpatient). Focus on other forms of research, such as qualitative research, should also be incorporated into systematic reviews.
Given the vast amounts of data, Bakken et al. (2008) identify areas of focus for health informatics in knowledge representation, data management, analysis, and predictive modeling in genomic health care and the need for policies and procedures to protect data acquisition, dissemination, privacy, security, and confidentiality as well as education in these areas. Informatics tools support professional practice, education of health care consumers, and knowledge generation. The technology is available now to incorporate evidence into reference links embedded in electronic clinical care plans. Incorporation of personalized clinical desktops to allow each clinician to have appropriate references (similar to Internet ad bot technology) provided to him or her may be possible. Time, research, and technology will tell.
These are amazing times. Technology has taken us faster and further than we ever thought possible. Health care jobs have become more technical and more complicated. In some ways, technology has increased the margin for error. Some health care practitioners will continue to rely on little scraps of paper and nonsystematic methods to keep themselves and their patients safe. Unfortunately, individuals who become so tied to these things close their mind to new innovations. The evolving quality culture and increased patient safety concerns are dragging health care workers forward. For the benefit of our patients, health care must move forward.
Collaboration, information literacy, improved access to online libraries, research tool transparency, a common data language, organizational and informational support, and continued research are a short list of needed items to advance translational research. Repeat studies are needed to provide meaningful meta-analysis and systematic reviews. Technology advancement in the area of incorporating evidence into clinical tools must continue. Removing the barriers to knowledge-seeking behavior and providing access to evidential resources will promote knowledge and, in the end, improve patient outcomes.
In the era of EBP, health care providers must continue to think critically about their actions. What is the science behind their interventions? Health care workers must no longer do things one way just because they have always been done that way. Research the problem, use evidence-based resources, critically select electronic and non-electronic references, consolidate the research findings and combine and compare the conclusions, present the findings, and propose a solution. One will be the first to ask why and may be a key player in making change happen.
1. Reflect on copyright law and why it is needed. Suppose you determine that photographs or other images can be replicated based on your assessment of fair use but your administrative assistant refuses to photocopy them because he feels that it is copyright infringement and against company policy. Describe in detail how you would handle this situation.
2. Choose a clinical problem or topic specific to your discipline and enter the search terms at http://www.guidelines.gov. Summarize the information you found there in relation to the recommendations for practice. How are they similar to what you have learned about the topic? How are they different? If you wanted to implement the recommendations for practice, what barriers might need to be overcome?
3. The use of heparin versus saline to maintain the patency of peripheral intravenous catheters has been addressed in research for many years. The American Society of Health System Pharmacists (2006) published a position paper advocating its support of the use of 0.9% saline in the maintenance of peripheral catheters in non-pregnant adults. It seems surprising that this position paper references articles that advocate the use of saline over heparin dating from 1991. What do you believe are some of the barriers that would have caused this delay in implementation?
In this text, we have established the importance of information literacy and how it can inform practice. For this content application scenario, choose an intervention from your discipline and find at least two recent scholarly articles related to the practice intervention.
1. How does the information in these articles compare to what your text has indicated is current practice?
2. If the articles suggest a change in current practice, how does this affect clinical work flow?
3. Share your discoveries with classmates and compare and contrast EBP findings for various interventions common to your discipline.
Agency for Healthcare Research and Quality
Eastern Michigan University
http://guides.emich.edu/c.php?g=217258&p=1435210
EBSCO
http://support.epnet.com/training/flash_videos/cinahl_basic/cinahl_basic.html
http://support.epnet.com/training/flash_videos/cinahl_advanced/cinahl_advanced.html
1. How do you acquire information? Choose 2 hours out of your busy day and try to notice all of the information that you receive from your environment. Keep diaries indicating where the information came from and how you knew it was information and not data.
2. Reflect on an IS with which you are familiar, such as the automatic banking machine. How does this IS function? What are the advantages of using this system (i.e., why not use a bank teller instead)? What are the disadvantages? Are there enhancements that you would add to this system?
3. In health care, think about a typical day of practice and describe the setting. How many times do you interact with ISs? What are the ISs that you interact with, and how do you access them? Are they at the patient’s side, handheld, or station based? How does their location and ease of access impact patient care?
4. Briefly describe an organization and discuss how our need for information and knowledge impacts the configuration and interaction of that organization with other organizations. Also discuss how the need for information and knowledge influences the nature of work or how knowledge workers interact with and produce information and knowledge in this organization.
5. If you could meet only four of the rights discussed in this chapter, which one would you omit and why? Also, provide your rationale for each right you chose to meet.