Quality improvement as a health care provider

Quality improvement As a health care provider, you are responsible for continuously improving the quality and safety of health care for your patients and their families through systematic redesign of health care systems in which you work. The Institute of Medicine (2001) defined quality health care as care that is safe, effective, patient-centered, timely, efficient, and equitable. Therefore, the goal of QI is to bring about measurable changes across these six domains by applying specific methodologies within a care setting. While several QI methods exist, the core steps for improvement commonly include the


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• Conducting an assessment

• Setting specific goals for improvement

• Identifying ideas for changing current practice

• Deciding how improvements in care will be measured

• Rapidly testing practice changes

• Measuring improvements in care

• Adopting the practice change as a new standard of care

Chapter 21 focuses on building your competence to participate in and lead QI projects by providing an overview of the evolution of QI in health care, including the nurse’s role in meeting current regulatory requirements for patient care quality. Chapter 19 discusses QI models and tools, such as cause-and-effect diagrams and process mapping, as well as skills for effective teamwork and leadership that are essential for successful QI projects.

As you venture through this textbook, you will be challenged to think not only about reading and understanding research studies, but also about applying the findings to your practice. Nursing has a rich legacy of research that has grown in depth and breadth. Producers of research and clinicians must engage in a joint effort to translate findings into practice that will make a difference in the care of patients and families.

Key points • Research provides the basis for expanding the unique body of scientific evidence that forms the

foundation of evidence-based nursing practice. Research links education, theory, and practice.

• As consumers of research, nurses must have a basic understanding of the research process and critical appraisal skills to evaluate research evidence before applying it to clinical practice.

• Critical appraisal is the process of evaluating the strengths and weaknesses of a research article for scientific merit and application to practice, theory, or education; the need for more research on the topic or clinical problem is also addressed at this stage.

• Critical appraisal criteria are the measures, standards, evaluation guides, or questions used to judge the worth of a research study.

• Critical reading skills will enable you to evaluate the appropriateness of the content of a research article, apply standards or critical appraisal criteria to assess the study’s scientific merit for use in practice, or consider alternative ways of handling the same topic.

• A level of evidence model is a tool for evaluating the strength (quality, quantity, and consistency) of a research study and its findings.

• Each article should be evaluated for the study’s strength and consistency of evidence as a means of judging the applicability of findings to practice.

• Research articles have different formats and styles depending on journal manuscript requirements and whether they are quantitative or qualitative studies.

• Evidence-based practice and QI begin with the careful reading and understanding of each article contributing to the practice of nursing, clinical expertise, and an understanding of patient values.

• QI processes are aimed at improving clinical care outcomes for patients and better methods of system performance.


Critical thinking challenges •  How might nurses discuss the differences between evidence-based practice and research

with their colleagues in other professions?

• From your clinical practice, discuss several strategies nurses can undertake to promote evidence- based practice.

• What are some strategies you can use to develop a more comprehensive critique of an evidence- based practice article?

• A number of different components are usually identified in a research article. Discuss how these sections link with one another to ensure continuity.

• How can QI data be used to improve clinical practice?

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.


References 1. Agency for Healthcare Research and Quality. Systems to rate the strength of scientific

evidence. File inventory, Evidence Report/Technology Assessment No. 47. AHRQ Publication No. 02-E0162002.

2. Al-Mallah M.H, Farah I, Al-Madani W, et al. The impact of nurse-led clinics on the mortality and mortality of patients with cardiovascular diseases A systematic review and meta-analysis. Journal of Cardiovascular Nursing 2015;31(1):89-95 Available at: doi:10.1097/JCN.00000000000000224.

3. American Nurses Association (ANA). Code of ethics for nurses for nurses with interpretive statements. Washington, DC: The Association;2015.

4. Cochrane Consumer Network, The Cochrane Library, 2016, retrieved online. Available at: www.cochranelibrary.com

5. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nursing Outlook 2007;55(3):122-131.

6. Institute of Medicine [IOM]. The future of nursing Leading change, advancing health. Washington, DC: National Academic Press;2011.

7. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm A new health system for the 21st century. Washington, DC: National Academy Press;2001.

8. Kastner M, Antony J, Soobiah C, et al. Conceptual recommendations for selecting the most appropriate knowledge synthesis method to answer research questions related to complex evidence. Journal of Clinical Epidemiology 2016;73:43-49.

9. Nyamathi A, Salem B.E, Zhang S, et al. Nursing case management, peer coaching, and hepatitus A and B vaccine completion among homeless men recently released on parole. Nursing Research 2015;64:177-189 Available at: doi:10.1097/NNR.0000000000000083.

10. Sackett D.L, Straus S, Richardson S, et al. Evidence-based medicine How to practice and teach EBM. 2nd ed. London: Churchill Livingstone;2000.

11. Sandelowski M, Barroso J. Handbook of Qualitative Research. New York, NY: Springer Pub. Co.;2007.

12. Uman L.S. Systematic reviews and meta-analyses. Journal of the Canadian Academy of Child and Adolescent Psychiatry 2011;20(1):57-59.

13. vanDijk J.F.M, Vervoot S.C.J.M, vanWijck A.J.M, et al. Postoperative patients’ perspectives on rating pain A qualitative study. International Journal of Nursing Studies 2016;53:260-269.

14. Whittemore R. Combining evidence in nursing research. Nursing Research 2005;54(1):56-62.


C H A P T E R 2


Research questions, hypotheses, and clinical questions Judith Haber

Learning outcomes

After reading this chapter, you should be able to do the following: • Describe how the research question and hypothesis relate to the other components of the research process. • Describe the process of identifying and refining a research question or hypothesis. • Discuss the appropriate use of research questions versus hypotheses in a research study. • Identify the criteria for determining the significance of a research question or hypothesis. • Discuss how the purpose, research question, and hypothesis suggest the level of evidence to be obtained from the findings of a research study. • Discuss the purpose of developing a clinical question. • Discuss the differences between a research question and a clinical question in relation to evidence-based practice. • Apply critiquing criteria to the evaluation of a research question and hypothesis in a research report.


clinical question complex hypothesis

dependent variable directional hypothesis

hypothesis independent variable

nondirectional hypothesis population

purpose research hypothesis

research question statistical hypothesis

testability theory


Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing


exercises, and additional research articles for practice in reviewing and critiquing.

At the beginning of this chapter, you will learn about research questions and hypotheses from the perspective of a researcher, which, in the second part of this chapter, will help you generate your own clinical questions that you will use to guide the development of evidence-based practice projects. From a clinician’s perspective, you must understand the research question and hypothesis as it aligns with the rest of a study. As a practicing nurse, developing clinical questions (see Chapters 19, 20, and 21) is the first step of the evidence-based practice process for quality improvement programs like those that decrease risk for development of pressure ulcers.

When nurses ask questions such as, “Why are things done this way?” “I wonder what would happen if . . . ?” “What characteristics are associated with . . . ?” or “What is the effect of ____ on patient outcomes?”, they are often well on their way to developing a research question or hypothesis. Research questions are usually generated by situations that emerge from practice, leading nurses to wonder about the effectiveness of one intervention versus another for a specific patient population.

The research question or hypothesis is a key preliminary step in the research process. The research question tests a measureable relationship to be examined in a research study. The hypothesis predicts the outcome of a study.

Hypotheses can be considered intelligent hunches, guesses, or predictions that provide researchers with direction for the research design and the collection, analysis, and interpretation of data. Hypotheses are a vehicle for testing the validity of the theoretical framework assumptions and provide a bridge between theory (a set of interrelated concepts, definitions, and propositions) and the real world (see Chapter 4).

For a clinician making an evidence-informed decision about a patient care issue, a clinical question, such as whether chlorhexidine or povidone-iodine is more effective in preventing central line catheter infections, would guide the nurse in searching and retrieving the best available evidence. This evidence, combined with clinical expertise and patient preferences, would provide an answer on which to base the most effective decision about patient care for this population.

Often the research questions or hypotheses appear at the beginning of a research article, but may be embedded in the purpose, aims, goals, or even the results section of the research report. This chapter provides you with a working knowledge of quantitative research questions and hypotheses. It also highlights the importance of clinical questions and how to develop them.

Developing and refining a research question: Study perspective A researcher spends a great deal of time refining a research idea into a testable research question. Research questions or topics are not pulled from thin air. In Table 2.1, you will see that research questions can indicate that practical experience, critical appraisal of the scientific literature, or interest in an untested theory forms the basis for the development of a research idea. The research question should reflect a refinement of the researcher’s initial thinking. The evaluator of a research study should be able to identify that the researcher has:

• Defined a specific question area

• Reviewed the relevant literature

• Examined the question’s potential significance to nursing

• Pragmatically examined the feasibility of studying the research question

TABLE 2.1 How Practical Experience, Scientific Literature, and Untested Theory Influence the Development of a Research Idea

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