Chapter 01: Evidence-Based Practice in Nursing
Craig: Evidence-Based Practice in Nursing, 7th Edition

MULTIPLE CHOICE

	1.	Research knowledge is now being transformed into clinical recommendations by expert panels and embedded into healthcare delivery systems. One example of this is a/an:
a.	Electronic prompt or reminder	
b.	Computer calendar	
c.	Magnetic identification badge	
d.	Electronic text books	

ANS:	A
Research knowledge is being transformed into clinical recommendations by expert panels and embedded into healthcare delivery systems in the form of, for example, electronic prompts or reminders. Technological developments have led to the increasing use of computerized decision support systems, which can include algorithms that generate case specific clinical recommendations. Computer calendars, magnetic identification badges, and electronic text books are not a part of the healthcare delivery system.

	2.	The new graduate nurse notices that what is being done at work is different than what was taught in school. The nurse notes that there was significant evidence for what was taught in school, but there is little evidence for what is being done at the bedside. In evidence-based practice, this is known as:
a.	Robust Evidence	
b.	Low quality evidence	
c.	Too much evidence	
d.	Gap in evidence	

ANS:	D
Historically, academic and clinical nursing existed as two separate entities, resulting in much research being unrelated to everyday nursing practice. This historical trend in research, of prioritizing professional issues over patient care issues, had important ramifications for nurses trying to make informed decisions about aspects of clinical care. Robust evidence is strong evidence. Low quality evidence is weak evidence. Too much evidence can be overwhelming to nurses and practitioners who are trying to keep up with the latest evidence-based information.

	3.	A nurse with many years of experience wants to work on a project that promotes a culture of evidence-based practice. The nurse focuses on which of the following key idea?
a.	Training that allows partnership with the patient	
b.	Training that ensures all patients get the same testing	
c.	Training on how to reduce testing by refusing to order tests	
d.	Training on which tests will take less time for the patient-centered	

ANS:	A
In their thought-provoking paper entitled “Evidence-based medicine: a movement in crisis,” Greenhalgh et al. (2014) point out the risk of a gradual slide toward the misuse of evidence, where algorithmic rules and prompts lead to a technocratic approach to care, in which patients are sent for tests or started on therapies without being offered personalized shared decision making and individualized care. Organizations therefore need a culture of supporting training and development so that health care practitioners are not just able to find and critically read research evidence, but are also able to apply their expert judgment and to have meaningful conversations with patients when reaching clinical decisions about care; the practitioner-patient relationship needs to be foremost if the founding principles of EBP are to be followed (Greenhalgh et al., 2014).

	4.	A nurse finds that there are a high number of laboratory specimens that are mislabeled and results are attached to the wrong patient’s chart. In the IOWA model, the nurse’s observation is known as the:
a.	Stakeholder	
b.	Trigger	
c.	Evidence	
d.	Research	

ANS:	B
The first step in the IOWA model is to identify triggering problems or opportunities that arise in the course of clinical practice or as a result of new data, new evidence, new initiatives, or regulations. This “trigger” generates a question. The next step is to reach a decision on whether the topic is a priority for the organization. If so, a team of stakeholders is assembled. They search for, critique, and synthesize the available body of evidence (weighing the quality, quantity, consistency, and risk of the evidence). If the evidence base is lacking, this flags an opportunity for future research.

MULTIPLE RESPONSE

	1.	Healthcare-associated infections across Europe most commonly include which of the following? (Select all that apply.)
a.	Pneumonia	
b.	Surgical site infections	
c.	Urinary tract infections	
d.	Oral infections	

ANS:	A, B, C
Across Europe, the estimated mean prevalence for HAI is 6% (country range 2.3%–10.8%) (European Centre for Disease Prevention and Control, 2013) with approximately 24% of those infections being pneumonia or lower respiratory tract infections, 20% surgical site infections, and 19% urinary tract infections. Oral infections are among not the most common healthcare-associated infections.

	2.	The steps in the evidence-based practice process include which of the following? (Select all that apply.)
a.	converting information needs about clinical problems into clear questions.	
b.	seeking evidence to answer those questions.	
c.	avoiding asking questions that challenge physicians’ current practice.	
d.	evaluating performance and the outcome of the decision.	

ANS:	A, B, D
The steps in the EBP process entail:
1) converting information needs about clinical problems into clear questions
2) seeking evidence to answer those questions
3) evaluating (critically appraising) the evidence for its validity (truthfulness) and usefulness
4) integrating findings with clinical expertise, patient needs, and patient preferences to reach a decision as to the optimum course of action, and then applying this decision
5) evaluating performance and the outcome of the decision.
It is key to ask questions, even if it challenges the current practice of a physician, in order to obtain evidence regarding the practice. If the evidence does not support the practice, then a change may be necessary.

	3.	Nursing competencies were organized around the five points of the ACE Star Model of Knowledge Transformation, which include which of the following? (Select all that apply.)
a.	identification	
b.	discovery	
c.	translation	
d.	evaluation	

ANS:	B, C, D
Specifically in nursing, EBP competencies were developed from several perspectives. In the US, following the recommendations that each health profession must develop its specific competencies, national consensus was established across a set of 82 competency statements; the competencies were organized around the five points of the ACE Star Model of Knowledge Transformation and include discovery, summary, translation, integration, and evaluation. Identification is not one of the five points of the ACE Star Model of Knowledge.

	4.	A nurse is discussing medication concordance with a patient who does not take their medication as prescribed. The patient reports that it is difficult to remember to take “so many pills.” The nurse evaluates the situation and prepares education based on which of the domain(s)? (Select all that apply.)
a.	Pharmacological	
b.	Psychosocial	
c.	Cognitive	
d.	Emotional	

ANS:	A, B
Concordance or adherence with drug therapy can be influenced by various factors including social and economic factors (e.g., level of social support, living environment, cost of drugs); the relationship between the patient and provider; the nature of the illness (with concordance a challenge for chronic illnesses treated over a long period); the medications themselves (e.g., the number of medications, number of daily doses, side effects); and patient factors (e.g., cognitive impairment, lack of knowledge, substance abuse). The approach to the problem of poor concordance with treatment therefore requires knowledge from the psychosocial and pharmacological domains. The cognitive domain includes knowledge, and the patient is aware that they need to take the medication. The emotional domain involves rewarding behavior and development of relationships.

	5.	A research study finds that men ages 30-40 are more likely to gain weight over a 10-year period. The study is conducted on diabetic patients who are not following a carb-controlled diet. The researcher notes which of the following to be true? (Select all that apply.)
a.	Not generalizable to all men ages 30-40	
b.	The study participants represent a population sub group	
c.	The evidence gathered applies to all men ages 30-40	
d.	The findings can be applied to men ages 40-50	

ANS:	A, B
It is crucial that evidence from studies undertaken with a specific population is not inappropriately and unthinkingly extrapolated to other population subgroups, such as to patients of a different age group. Care should be taken if extrapolating research findings from such trials to other people who could have several coexisting conditions or other unique risk factors that may prevent them from attaining the same results as those attained by the trial participants. Healthcare organizations and individuals are responsible for ascertaining whether or not evidence is likely to be generalizable to their patient populations. The study is specific to men ages 30-40 who are diabetic and not on a carb-controlled diet. The evidence is not generalizable and the participants represent a population sub group. The evidence cannot be applied to all men because not all men are diabetic, nor can it be applied to men outside of the age range in the study.

COMPLETION

	1.	IOWA and ACE Star are _____________ that allow us to conceptualize the operationalization of evidence-based practice.

ANS:	
models

The ACE Star Model of Knowledge Transformation and the IOWA model allow us to conceptualize the process of “operationalizing” EBP. They can contribute to our understanding of how to change practice in the light of best evidence within the context of knowledge translation/implementation science.