Abstract
There are several definitions of EBP,2–4 but all definitions include some combination of the best research evidence, the best practice experience, and the consideration of patient values and preferences. This sounds simple enough, but there is often a disconnect that occurs between the idea of EBP and the actual delivery of evidenced based care. The problem is multifaceted, but some reasons include a shortage of healthcare professionals skilled in the actual process of locating, critiquing, and synthesizing evidence; difficulty integrating best practice recommendations into the clinical setting; and, even more problematic, the lack of an established evidence base for some clinical questions.
A shortage of healthcare workers who are adequately educated and prepared to conduct EBP is a well-described problem.5,6 While the concept of EBP is now taught in schools, the actual conduct of EBP is more complex. It requires the ability to search for and locate evidence, knowledge of research design and statistical analyses, and skill for synthesizing the findings from multiple research studies into recommendations. The increasing number of clinical doctorate programs, such as the doctor of nursing practice (DNP) and the doctor of physical therapy (DPT), should be preparing the new generation of practitioners with the skills and abilities to conduct EBP adequately. However, there is still a large number of practicing nurses and allied health professionals who obtained their degrees before EBP was integrated into the curricula.
In this issue of Bariatric Nursing and Surgical Patient Care, Ernst and colleagues provide a detailed review of studies that examined the best ways to prevent respiratory dysfunction in bariatric surgery patients with obstructive sleep apnea. Literature reviews such as this are an important contribution because they provide a detailed description of the work that represents the necessary first step in developing EBP recommendations and clinical practice guidelines. It is important for nurses and other healthcare providers with EBP skills to disseminate the results of their EBP projects and to advance that work purposefully toward the development of evidence-based protocols and clinical practice guidelines. In 2008, NABN developed and published three different clinical practice guidelines: Best Practices for Skin Care of the Morbidly Obese, 7 Best Practice for Sensitive Care and the Obese Patient, 8 and Best Practices for Safe Handling of the Morbidly Obese Patient. 9 This is exactly the type of work that needs to continue in order to improve the quality of care for bariatric patients.
Once best practices have been identified and practice recommendations have been made, translation and integration of this evidence into practice is challenging for several reasons. First, change is always difficult; the concept of early adaptors and laggards 10 has been well described, but these individual characteristics are only one part of the translation challenge. Healthcare and healthcare delivery are complex. Not only are there competing priorities for and various drivers of program implementation, but these factors are then layered onto a structure where the systems and processes for the actual “doing” of work are complicated. It is rare that any healthcare process, even one as seemingly simple as assisting a patient with self-care, exists independently of other processes. As a result, any practice change usually involves many departments and people, and the competing goals and objectives of these stakeholders can become a barrier. In fact, during this issue's roundtable discussion about safe patient handling, these very issues are identified and discussed.
Translation science is defined as the “investigation of methods, interventions, and variables that influence the adoption of EBP.” 11 Theoretical models of translational science include the interaction of EBP characteristics with the intended users, within the contextual factors of the organization.11–13 These models are useful for understanding the complexities of translating a particular EBP change and can assist in implementation. It is also important to note that collaboration with colleagues in quality improvement (QI) may help in this final step of the EBP process, as gaining the support of stakeholders, modifying processes, and ultimately impacting outcomes has been part of QI work for some time.
Finally, nursing is a profession that is rich in history and tradition, and as a result, there are some non-evidence based nursing practices that have remained “sacred” over time. 14 In today's healthcare environment, it is no longer acceptable to continue a practice because it is the way it has always been done. If you are fortunate enough to work in a setting with EBP and translation experts, then perhaps you and your colleagues have already questioned a common practice and have sought to embark on an EBP project only to discover that there is no research base to answer the clinical question. In these situations, the feedback loop between clinical practice, EBP, and research is essential.
Last year, a group of nurses at an academic medical center questioned the accuracy of capillary blood glucose values in postoperative patients with obesity. Physiologic factors in this patient population suggest that capillary blood glucose levels might be different from venous blood glucose levels, and if so, capillary blood glucose levels might not be a valid or reliable measure of actual blood glucose. After reviewing the literature, the team found that capillary blood samples measured by point of care glucometers are approved for use in stable ambulatory diabetic patients, but they found no evidence to support its use as a reliable and valid measurement technique for postoperative patients with obesity in an acute care setting. With support from their Director of Nursing Research and Evidence Based Practice, the nurses applied for the annual NABN research grant and ultimately received funding to answer this important clinical question. The study is ongoing, but this example highlights the extent to which bariatric nurses and all bariatric care providers need to question every piece of their practice and ensure that there is supporting research pertinent to the bariatric patient population.
According to Dr. Avedis Donabedian, the father of quality improvement, clinical outcomes are the ultimate validation of high quality care. 15 Donabedian's structure–process–outcome model posits that care delivery processes are contributors and antecedents to patient outcomes. It is in the processes of care delivery that EBP plays a role. As healthcare providers, we have a duty to ensure that care processes for all patients include the practices that have been linked to the best outcomes and when evidence is not available to support practice, to ask the proper research question and discover the evidence.
Quality care of the bariatric patient necessitates a team approach. It is encouraging, then, that key members of the care team, such as nurses, physicians, physical therapists, pharmacists, and nutritionists, are now all receiving formal education and training about how to conduct EBP. This should hopefully facilitate a multidisciplinary approach to evidence-based care, which may help remove some barriers and ultimately improve the quality of care provided to this unique and complex patient population.