DIFFERENTIATING RESEARCH, EVIDENCE-BASED PRACTICE, AND QUALITY IMPROVEMENT

Research, EBP, and QI are among the most frequently used terms in healthcare; yet, the terms are often misused and misunderstood (Christenbery, 2018; Melnyk & Fineout-Overholt, 2019). With the increasing interest and mandates (AACN, 2006) to incorporate these terms into daily clinical practice, it is imperative that DNP students, as role models, use each term seamlessly. Inaccurate definitions and misuse of the three terms lead to diminished credibility of a DNP project paper.

Research

Research is defined as the collection, analysis, and interpretation of data about a specific subject (Polit & Beck, 2019). The encompassing principle of research is to answer questions for the purpose of generating new knowledge (Christenbery, 2018). Two primary approaches to nursing research are recognized: quantitative and qualitative. Though these research approaches are dissimilar, they frequently intersect. In basic terms, quantitative research is the rigorous and systematic collection and analysis of numeric data. Qualitative research is the studied use and collection of diverse resources, including, but not limited to, case studies, personal experience, group experiences, artifacts, cultural texts, and historical narratives (Denzin & Lincoln, 2005). The incorporation of qualitative and quantitative strategies within a single study is referred to as mixed-method research or triangulation (Polit & Beck, 2019).

Evidence-Based Practice

There are many definitions of EBP used across healthcare disciplines (Stetler et al., 1998). EBP, from a nursing perspective, is widely defined as “a problem-solving approach to the delivery of health care that integrates best evidence from studies and patient care data with clinician expertise and patient preferences and values” (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2010). This definition acknowledges that DNP students integrate forms of high-quality data, clinical expertise, and patient values that lead to optimal patient outcomes.

Quality Improvement

The term QI refers to deliberate and defined data-driven activities that aim at immediate improvements in healthcare processes, costs, productivity, professional development, and healthcare outcomes (Batalden & Davidoff, 2007). QI requires continuous efforts to lessen process variation (e.g., antibiotic use for type of bacteria associated with COPD,) and improve the outcomes of these processes (e.g., less cost for antibiotic use for common COPD infections) for patients and healthcare organizations. QI involves multiple stakeholders in the reduction or elimination of waste and loss of time, energy, and resources (Batalden & Davidoff, 2007).

Table 1.1 is a guide to clarify salient differences between research, EBP, and QI.

ESTABLISHING EVIDENCE

The message is indisputable: DNP students must be certain that patients and populations receive care built on the best available evidence (AACN, 2006). Evidence is defined as knowledge derived from diverse and credible sources (Christenbery, 2018; Higgs & Jones, 2000; Rycroft-Malone et al., 2004). Before engaging in a project that requires sound evidence and subsequently writing a project paper, DNP students must be clear about what constitutes evidence and how, as practitioners, they will use evidence in making critical healthcare decisions. Related, in part, to the complexity of DNP projects, a strong and broad evidence base is required to deliver optimal patient-centered care.

Table 1.1

Differences Between Research, Evidence-Based Practice, and Quality Improvement

Distinguishing Criteria	Research	Evidence-Based Practice	Quality Improvement
Purpose	Discover, explore, predict, or prescribe phenomena.Verify existing knowledge or create new knowledge.	Translate research and best evidence into practice.Encourage clinical practice based on evidence as opposed to tradition.Optimize effectiveness of current interventions.	Foster immediate improvement in a healthcare setting.Compare organizational standards to national benchmarks.Improve cost-effectiveness.Make workflow more efficient and safer.
Impact on Practice	Generates new knowledge.Contributes to theory development.	Improve outcomes through translation of evidence into practice.	Improve patient care processes (e.g., Optimizing sepsis care) and health outcomes in local settings.
Methodologies	QuantitativeQualitative	ACE Star Model of Knowledge TransformationAdvancing Research and Clinical Practice Through Close Collaboration (ARCC Model)Clinical Scholar ModelIowa Model of EBPJohns Hopkins EBP ProcessPromoting Action on Research Implementation in Health Services (PARIHS Framework)Settler Model	Plan-Do-Check-ActPlan-Do-Study-ActSix SigmaLean Six Sigma
Historical Roots	Strongly influenced by scholars who used the scientific method in the 17th century.	Originated in medical disciple in the late 20th century.	Business and industry sectors.
Population of Interest	Populations for whom the findings may be generalized (quantitative) or transferable to select groups (qualitative).	Specific unit (e.g., burn unit at a medical center) or population (adults over 65 in rural east Tennessee county with heart failure).	Limited to specific healthcare unit or organization.
Examples	Identifying effective coping skills for young adults with cystic fibrosis.Predicting risk of HIV in young inner-city Asian males.	Overcoming administrative barriers to adolescent depression screening for school nursesImplementation of maternal sepsis screening tool.	Improving patient adherence to colonoscopy preparation at local clinic.Decreasing patient wait time for ophthalmology appointments.

EBP, evidence-based practice

Effective change in patient care can be best achieved through the use of several sources of evidence. Generally, those sources of evidence are considered to be: (1) research, (2) clinical experience, (3) patients, and (4) context (Rycroft-Malone et al., 2004).

RESEARCH

Research is a methodical and meticulous investigation into a specific issue, concern, or problem (Polit & Beck, 2019). Because research is a systematic and rigorous endeavor, it generally receives a higher level of evidence rating than other forms of evidence such as clinical practice guidelines (Christenbery, 2018; Melnyk & Fineout-Overholt, 2019). In addition, for better or worse, research evidence often attains a perceived status of having unquestionable certainty and durability. However, unless DNP students approach research findings with an understanding that all research has limitations and is questionable to some degree, their project papers may contain serious misconceptions that may negatively influence patient care outcomes (Rycroft-Malone et al., 2004). First, DNP students need to know that definitive studies are highly uncommon. Researchers live in a relative world and proof is seldom, if ever, established (Godfrey-Smith, 2003). Research used to support DNP studies should be viewed as conditional, and the accepted current research base for practice should be viewed as temporal and constantly evolving (Rycroft-Malone et al., 2004).

Fast Facts

Throughout the project and writing process, DNP students should recheck the literature for pertinent research updates about their topics.

Second, while quantitative researchers attempt to gain a high level of objectivity, research occurs in a historical and social context. Thus, research is not value-free, acontextual, or static (Iaccarino, 2001). Because research is dynamic and influenced within a historical context, stakeholders (e.g., patients, healthcare providers) will have their own interpretations and philosophical views of the research findings, which may or may not correspond with interpretations of DNP students. Because multiple interpretations of research will be held by stakeholders, it is unrealistic to believe that simply providing them with core research findings will impact or change clinical practice (Rycroft-Malone et al., 2004). Research is central to EBP, yet more than research evidence is required to change healthcare practitioners’ decision processes and modify patient values to improve healthcare outcomes. Past clinical experiences profoundly influence a practitioner’s interpretations of research.

CLINICAL EXPERIENCE

Clinical experience enables practitioners to amass important knowledge for the improvement of patient-centered care. Knowledge gained from clinical experience is sometimes referred to as craft knowledge or practical know-how (Rycroft-Malone et al., 2004). Craft knowledge is described as intuitive or implicit. Nurses draw on their own clinical knowledge and depend on the knowledge of other healthcare providers to inform care. Clinical knowledge is an invaluable key for integrating research into contextual boundaries of practice (Rycroft-Malone et al., 2004). DNP students must be certain that nurses’ clinical knowledge is understood and made explicit for the DNP project to be successfully implemented. Evaluation of nurses’ clinical knowledge, pre- and post-intervention, is an invaluable part of the project paper and is essential for appropriate dissemination of a project intervention to specific clinical settings. It behooves DNP students to invest time in the clinical field helping nurses explicate and elucidate their clinical understandings and narratives. Understanding a nurse’s existing knowledge is a prerequisite to implementing best evidence into practice settings. All project papers must emphasize the clinical knowledge nurses possess in a given setting so that transferability of the project’s findings may be maximized.

PATIENT EVIDENCE

Patients inform DNP projects with their personal knowledge and experiences. DNP students understand that the impact of their project implementations is dependent on the various ways patients and their families understand and respond to the interventions. Clearly, absolute generalization of research findings is unachievable when considering the unique complexity of patients within a population compared to patients within a particular study (Polit & Beck, 2019). DNP students will need to assess patients’ previous experiences with healthcare, physical and psychosocial knowledge about themselves, and their values about healthcare before an intervention can be successfully implemented (Rycroft-Malone et al., 2004). These assessments are germane to a DNP project and are essential information to be included in the project paper. Without adequate information patient information, other practitioners will lack the knowledge for successful transference of a project’s outcomes to the select populations they care for.

CONTEXT AS EVIDENCE

Context, the circumstances that form a setting, contains multiple sources of useful evidence. Awareness of contextual sources of evidence is indispensable in the delivery of best clinical practices. Sources of contextual evidence that are generally accessible to nurses include evaluation data, internal research findings, QI data (e.g., Plan, Do, Study, Act cycle), patient and family input, institutional knowledge (e.g., organizational hierarchy), professional networks, stakeholders, and institutional policy (Rycroft-Malone et al., 2004). Recognition of contextual sources of evidence contributes to the diversity of information that enriches the delivery of care addressed in DNP projects and project papers. Stetler (2003) identifies contextual evidence as internal evidence that is gathered systematically from sources within specific practice environments. DNP students need to be cognizant about how contextual data is collected, analyzed, and interpreted before integrating the data into clinical decision-making opportunities for their DNP projects.

OPTIMIZING ADVISOR RELATIONSHIPS

The advisor-student relationship is the sine qua non for DNP program success. Advisors in DNP programs generally assume a Chair role for the DNP Project Team. Advisors help students with topic identification and refinement, provide oversight of project progress, lead the project faculty team, and evaluate the level of project and project paper success. Working with an invested advisor advances the likelihood of completing the required work in a doctoral program. Productive relationships among student, Chair, and project team members are essential for developing and completing a well-rounded and successful project. The following recommendations may help facilitate DNP student and faculty cohesiveness

Prior to beginning a DNP program, it is wise to review potential faculty who might best serve as an advisor. If a particular faculty member seems like a sensible fit, it is perfectly acceptable to request to have that faculty member assigned as an advisor. Sensible fit is identified, in part, as a faculty member with similar interests and areas of practice as the student. Similar interests can be determined by reviewing publication topics and numbers of publications. For example, if a student’s interest is renal failure in pediatric patients, the student may want to select an advisor who has published in that area and in pediatric journals specifically. Students may also review the faculty member’s podium and poster presentations to determine if they are focused on compatible areas of interest. It is reasonable to ask the DNP department head the number of DNP students a faculty member has served as advisor/chair, the topics covered for each project, and the average number of years it took students to complete the scholarly project while being supervised by a faculty member.

SUMMARY

Understanding the quality and impact of DNP projects helps lead to successful DNP project papers. DNP projects greatly influence healthcare and are often deserving of widespread dissemination through publication. This chapter puts forth critical preliminary ideas that help ensure DNP projects and DNP project papers are conceptualized and created in a way that will support successful completion and further dissemination to the healthcare and scientific communities.

References

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