Translational Research:

Generating Evidence for Practice

 Objectives
• Clarify the differences between
evidence based practice and
translational research.
• Describe models for introducing
research findings into practice.
• Identify barriers to research
utilization in practice.
 Introduction
• Evidence-based practice, translational
research and research utilization are all
words which have been used to describe
the application of evidential knowledge to
clinical practice.
• In evidence-based practice, the goal is to
decrease practice variability, increase
patient safety and eliminate unnecessary
cost.
 Clarification of Terms
• Research utilization is a subset of
evidence-based practice.
• Translational research is used to
describe the translation of medical,
biomedical, informatics and nursing
research into bedside clinical
interventions.
• Research results are crucial to
furthering evidence-based practice.
 Clarification of Terms
• Discussion abounds in the area of what
constitutes evidence.
• Considered the most reliable, the randomized
control trial (RCT) is often termed the gold
standard for evidence.
• Evidence includes standards of practice,
codes of ethics, philosophies of nursing,
autobiographical stories, esthetic criticism,
works of art, qualitative studies and the
patient and clinical knowledge.
 Clarification of Terms
• In order to use evidence in practice,
the weight or validity of the research
must be determined.
• An example of an evidential hierarchy
by Stetler et al. (1998) prioritizes
evidence into 6 categories:
– Meta-analysis
– Individual experimental studies
– Quasi-experimental studies
– Non-experimental studies
– Program evaluations such as quality improvement
projects
– Opinions of experts
 Clarification of Terms
• The hierarchy identifies meta-analysis as
the best quality evidence since it utilizes
multiple individual research studies to
come to consensus.
• Qualitative research allows us to
understand the way in which the
intervention is experienced to the
researcher and to the participant as well
as the value of the interventions to both
parties.
 Bridging the gap between
research and practice
• Bridging the gap between research
and practice requires an
understanding of the key concepts and
barriers, accessibility to research
findings, access to clinical mentors for
research understanding, a reinforcing
culture and a desire on the part of the
clinician to implement best practices.
 Bridging the gap between
research and practice
• Barriers to the application of evidence-
based practice are lack of time, lack of
access to libraries within their facility,
lack of technology confidence, lack of
knowledge on how to search for
information and lack of value assigned
to using research in practice.
 Bridging the gap between
research and practice
• In an observational study of the
information seeking behaviors of on-
duty nurses, McKnight (2006) noted
that nurses did not feel ethically
comfortable with taking time from
patient care to read publications, nor
was much time available.
• Nurses may see the job of interpreting
research as too complex or may see
the organizational culture as a barrier to
implementation.
 The role of informatics
• The collaborative component of
research is supportive of informatics
science.
• Technology has become so important
to research that the National Institutes
of Health has invested in re-
engineering of the clinical research
enterprise as part of its roadmap
initiative for medical research
(National Institutes of Health, 2007).
 The role of informatics
• An informatics infrastructure is critical to
supporting a clinician’s access to
information in a clinical setting.
• As an example of the integration of
informatics and the medical record, Matter
(2006) describes the positive effects of a
successful integration of referential links
with EBP clinical content in the clinical
pathway on patient outcomes.
 The role of informatics
• The Cochrane Collaboration showed
an increasing need to improve on the
speed of knowledge acquisition and
access to evidence.
• With the goal of promoting the use of
research findings, and tool use based
on these findings, the Agency for
Health Care Research (AHRQ)
became an active participant in
pushing evidence forward into practice.
 The role of informatics
• The AHRQ is a government sponsored
organization with the mission of
reducing patient risk from harm,
decreasing healthcare cost and
improving patient outcomes through
the promotion of research and
technology applications focused on
evidence-based practice.
 The role of informatics
• As part of an AHRQ initiative, the
National Guideline Clearinghouse
(NGC) was developed.
• NGC is a comprehensive database of
evidentially based clinical practice
guidelines and related documents
which are regularly published through
the NGC listserv and are available on
the NGC website
(http://www.guideline.gov/).
 The role of informatics
• The NGC website allows users to browse the
website for the clinical guidelines, view
abstracts and full text links, download full text
clinical guidelines to personal digital assistive
(PDA) devices, obtain technical reports and
compare guidelines.
• There are a growing number of written and
electronic resources available to assist in
creating guidelines and offering information
about evidence-based practice.
Developing evidence based
practice guidelines
• Careful analysis and discussion of the
research and/or other forms of
evidence in this scenario may reveal
that given the context, implementation
may not be practical.
• Information technology is important in
synthesizing the research regardless
of the model.
 Meta-analysis and
Generation of knowledge
• 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.
 Meta-analysis and
Generation of knowledge
• Meta-analysis, a form of systematic
review, uses statistical methods to
combine the results of several studies.
• Meta-analysis is “the statistical
analysis of a large collection of
analysis results from individual studies
for the purpose of integrating the
findings.”
 Meta-analysis and
Generation of knowledge
Steps of a meta-analysis are:
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
5. sensitivity testing to determine if the combined
results are the same
 Meta-analysis and
Generation of knowledge
• The often sited criticism of meta-analysis
is that emphasis is on quantitative studies,
not qualitative.
• The analysis is only as good as the
studies used in the analysis.
• Collection and dissemination of these
meta-analysis and systematic reviews are
available in paper and on-line through the
internet, although many such databases
require a subscription.
 Meta-analysis and
Generation of knowledge
• There are two vehicles for Open Access:
– archives
– journals
• Open Access journals are generally peer-
reviewed and freely available.
• The publishers of open access do not
charge the reader but obtain funds for
publishing elsewhere.
• Open access journals may charge the
author for publishing.
 Thought Provoking Questions
1. Twelve hour shifts are problematic for patient and
nurse safety and yet hospitals continue to keep the
12-hour shift schedule. In 2004, the Institute of
Medicine (Board on Health Care Services & Institute
of Medicine, 2004) published a report which referred
to studies as early as 1988 which discussed the
negative affects of rotating shifts on intervention
accuracy. Workers with 12 hour shifts realized more
fatigue than workers on 8 hour shifts. In another
study done in Turkey by Ilhan et al(Ilhan, Durukan,
Aras, Turkcuoglu, & Aygun, 2006), factors relating to
increased risk for injury were: age of 24 or less, less
than 4 years of nursing experience, working in the
surgical intensive care units and working for more
than eight hours. As a clinician reading these
studies, what would your next step be?
 Thought Provoking Questions
2. 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 recently
Pharmacists (ASHSP) published a position paper in
January 2006 (American Journal of Health System
Pharmacists, 2006) advocating their support of the
use of 0.9% saline in the maintenance of peripheral
catheters in non-pregnant adults. It seems
surprising that their position paper references
articles that advocate the use of saline over heparin
dating from 1991. What do you feel are some of the
barriers which would have caused this delay in
implementation?