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Knowledge Utilization: The “Classical” Approach

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  1. Knowledge Utilization:The “Classical” Approach Marita G. Titler, PhD, RN, FAAN Director of Research, Quality and Outcomes Management Department of Nursing Services and Patient University of Iowa Hospitals and Clinics and Clinical Professor University of Iowa College of Nursing Linda Q. Everett, PhD, RN Associate Director, University of Iowa Hospitals and Clinics Director, Department of Nursing Services and Patient Care/Chief Nursing Officer University of Iowa Hospitals and Clinics

  2. Purpose • To discuss the classical approach to knowledge transfer - “experts” generate knowledge and “help” organizations with implementation strategies

  3. Quality Clinical Practice Apply Findings in Practice Identify Questions Disseminate Knowledge Conduct Research Generate New Knowledge

  4. Overview • Definitions and assumptions • View of individual and organizational perspectives • Overview of science of TRIP • Example TRIP study - issues • Issues in knowledge transfer

  5. Knowledge Utilization • Application of evidence from randomized clinical trials as well as other types of scientific investigations and other types of knowledge (e.g. case reports, expert opinion) (Cook, 1998; Feinstein & Horwitz, 1997; Guyatt, Sackett, Sinclair et al , 1995; Stetler, Morsi, Rucki et al, 1998; Titler, Kleiber, Steelman et al, 2001)

  6. Evidence-Based Practice • Conscientious and judicious use of current best evidence to guide health care decisions (Dickersin & Manheimer, 1998; Rochon, Dikinson, Gordon, 1997; Sackett, et al, 1996)

  7. Research Utilization • A process of using research findings as a basis for practice. It encompasses dissemination of scientific knowledge, critique of studies; synthesis of findings, determining applicability of findings, application/implementation of scientific findings in practice, and evaluating the practice change.

  8. Research Utilization Evidence-Based Practice Figure 1

  9. Translational Research • Testing the effect of interventions for promoting adoption of evidence-based practices • Outcomes-rate and extent of healthcare providers use of these practices (Titler & Everett, 2001)

  10. Individual and Organizational Perspective • Individual perspective • Variation in practice • Governed by organizational SOC • Organizational perspective • Change in SOC - change in practices by individuals • System changes • Access to evidence • Organizational infrastructure • Combination of both

  11. Models of Evidence-Based Practice • Several models for promoting use of evidence-based practice • Individual practitioner perspective • Organizational perspective • Nursing • Interdisciplinary (Cronenwett, 1995; Demakis et al, 2000; Dufault, 2001; Foxcroft et al, 2002; Goode & Piedalue, 1999; Horsley et al, 1978; Logan et al, 1999; Rosswurm, 1999; Rubenstein et al, 2000; Rutledge & Donaldson, 1995; Stetler, 2001)

  12. Diffusion of Innovation Model (Rogers, 1995) • Social science • Framework for knowledge utilization studies • Empirical testing by various disciplines

  13. Social System Rate & Extent of Adoption Characteristics of the Innovation Communication Process Communication Users of Innovation Adoption of Innovation (Rogers, 1995) Figure 2

  14. Issues in TRIP • Access and synthesis • Isolation from colleagues - knowledgeable of research findings • Little known about the science of TRIP

  15. Issues in TRIP • Single Site • Non-experimental designs • Test one or two strategies • Sustainability of change • Multi-site experimental design

  16. Model to Guide Research Titler & Everett (2001). Critical Care Nursing Clinics of North America Figure 3

  17. From Book to Bedside: Acute Pain Management in the Elderly Funded by AHRQ RO1 HS10482 University of Iowa Iowa City, Iowa Principal Investigator Marita G. Titler, PhD, RN, FAAN Co-Principal Investigator Keela Herr, PhD, RN Project Director Gail Ardery, PhD, RN Investigators John Brooks, PhD Kathleen C. Buckwalter, PhD, RN, FAAN William Clarke, PhD Stacey Cyphert, PhD Investigators Linda Everett, PhD, RN R. Edward Howell, MS Meridean Maas, PhD, RN, FAAN J. Lawrence Marsh, MD Janet C. Mentes, PhD, RN Linda Rubenstein, PhD Margo Schilling, MD Bernard Sorofman, PhD Toni Tripp-Reimer, PhD, RN, FAAN Xianjin Xie, MS

  18. Experimental Design RO1 HS10482

  19. Characteristics of the EBP • Localization of the guideline (Burns et al, 1997; Newton, et al 1996; Shortell et al, 1995; Soumerai et al, 1998) • Practice prompts (Bakersville et al, 2001; Chamber et al, 1989; Cook et al, 1997; Hunt et al, 1998; O’Connor et al, 1996; Oxman et al, 1995; Schulte et al, 2001) • Clinical systems • Computerized decision-support • Practice prompts (algorithms) RO1 HS10482

  20. Opinion Leader • Practitioner within a specific discipline (nurse, physician, administrator) • Viewed as an important and respected source of influence amongst peer group • Role expectations: • Organizational leadership • Experts in practice • Promote needed changes in organizational infrastructure (e.g., documentation systems) to support evidence-based practice (Bero et al, 1998; Elliott et al 1997; O’Brien et al, 2002; Oxman et al, 1995; Soumerai, 1998; Valante & Davis, 1999)

  21. Change Champions • Organizational change • Expert clinician • Perceived as informal leader • Passionate about topic • Positive working relationship with other health care professionals (Backer et al, 1986; Backer, 1987; Backer, 1995; Greer, 1988; Rogers, 1995; Titler, Moss et al, 1994; Titler, 1998; Titler & Mentes, 1999)

  22. A change champion believes in an idea; will NOT take no for an answer; is undaunted by insults and rebuff; and above all, persists.

  23. Outreach/Academic Detailing • One-on-one meeting with practitioners in their setting • Convey information on: • New practice/innovation • Provider performance • Issues encountered

  24. Strategic Plan Vision Mission Philosophy of Care Four Building Blocks Leadership Recognition and Rewards Resources and Governance Performance Expectations

  25. Route - IM Use January 1, 1999 - December 31, 1999 Baseline Data

  26. January 1, 1999 - December 31, 1999 Baseline Data Demerol 52.2% Demerol 40% 65.7% 34.7% Morphine 47.8% Morphine 60% 2.0% All Experimental Sites (N=398) All Experimental Sites (N=398) All Experimental Sites (N=398) Site “S” (N=70) Site “S” (N=70) Site “S” (N=70) With Basal Rate Analgesics Used PCA Orders PCA Orders 26.1%

  27. Percent (%) with Pain Reassessed Within 60 Minutes Following Administration of Analgesic(N=Analgesic Administrations)Note: Does not include PCA administrations.

  28. Model to Guide Research Figure 4 Rogers, 1995 RO1 HS10482

  29. Design and Measurement Issues • Definition/terms • Unit of analysis • Determining practice patterns • Sensitivity of measures to detect change • Subjects • Frequency of data collection • Data sources

  30. Selection of Dependent Measures • Directly related to research question/specific aim • Dependent construct(s) • Adherence of nurses to the evidence-based guideline will occur more rapidly in experimental group versus control group • Rate of adoption

  31. Dependent Variables: Adherence to Guideline • Pain assessment practices • Pharmacological administration practices • Nonpharmacological pain treatments • Assessment of pain treatment side effects

  32. Data Sources • Direct observation • Patients • Nurses, physician self-report • Nurse, physician behavior - medical record abstraction

  33. Selection of Records • Records of patients admitted (January 1, 1999 to December 31, 1999) to one of 12 Midwest hospitals for hip fracture (ICD-9 820.***) • 65 years of age or older • Not in an ICU during first 72 hours following admission • Random selection of eligible subjects

  34. Preliminary AnalysisPain Assessed Every 4 Hours(N=709 Medical Records) January 1, 1999 - December 31, 1999 Baseline Data RO1 HS10482

  35. Pain AssessmentMean Percent of Four-Hour Time Blocks(N=709 Medical Records) January 1, 1999 - December 31, 1999 Baseline Data RO1 HS10482

  36. January 1, 1999 - December 31, 1999 Baseline Data (N=95) (N=149) (N=405) (N=190) (N=365) (N=46) (N=208) (N=124) Demerol and Propoxyphene Administration(N=709 Medical Records)

  37. January 1, 1999 - December 31, 1999 Baseline Data Other = 1.4% Codeine = 6.0% Parenteral Fentanyl = 2.3% Oxycodone = 7.9% Propoxyphene = 11.8% Hydrocodone = 15.6% Morphine = 23.7% Demerol = 31.0% Profile of Opioid AdministrationsOver 72 Hours(N=5721 Opioid Administrations)

  38. Use Always 4 3.5 - 4.0 3.6 ! 3.4 ! Use Sometimes 2.5 - 3.49 2.9 & 3 2.8 2.8 2.8 ! & & 2.4 & 2.8 Persuaded Implementation 2.1 ! 1.5 - 2.49 2 Aware .5 - 1.49 1 Not now 0 Elder Assess Confused Elder A-T-C Avoid Use p < .001 Assess Analgesic of Demerol p < .001 ! & Nurses Physicians Extent of Adoption Scores by Stage of DiffusionNurse and Physician Self-Report (Baseline) RO1 HS10482

  39. Dependent Variable Barriers • Barriers to Optimal Pain Management Questionnaire (baseline, 12, 24 months) • Barriers to optimal pain management • Physician and nurse version • Internal consistency - .79 RO1 HS10482

  40. 1.7 ± 0.7 Lack knowledge (nurse only) 2.3 ± 1.1 Pain expert not available 2.2 ± 0.9 1.5 ± 0.7 Lack consultation peers 1.6 ± 0.7 * Difficulty contacting/comm. 1.8 ± 0.8 1.5 ± 0.7 w/physician/nurse 1.6 ± 0.8 Limited access to pharmacist 1.7 ± 0.8 * Communication w/physician 1.8 ± 0.8 1.5 ± 0.8 /nurse-analgesic changes 2.5 ± 0.7 Difficulty communicating -patients 2.6 ± 0.8 1.6 ± 0.8 *Conversion of drugs 2.2 ± 0.9 2.2 ± 0.7 *Lack of in-depth assessment 2.5 ± 0.6 1 1.5 2 2.5 3 3.5 4 Little Extent Moderate Extent Great Extent No Extent * p value < .05 Nurses (N=172) Physicians (N=51) Barriers to Managing Acute Pain in Elders Baseline Data RO1 HS10482

  41. Organizational Variables • Organization Assessment Instrument - CNE • Case mix index • Skill mix • ADC • Bed capacity • Use of nursing research in practice (Stiefel, 1996) • 9 elements – systems perspective • Test-retest (r=.84) • CNE • Organization’s stage of adoption of pain management practices • Staff nurses RO1 HS10482

  42. Adoption/Implementation Stage p < .001 RO1 HS10482

  43. Characteristics of Nurses and PhysiciansQuestionnaires (Baseline, 12, 24) • Attitudes toward guidelines • Likelihood (1-4) of CPGs to result in certain actions • Innovativeness instrument • Willingness to change/adopt new ideas • Demographics RO1 HS10482

  44. 5.6 + 0.7 5.5 + 0.8 5.4 + 0.8 5.4 + 0.9 5.2 + 0.8 5.1 + 0.8 5.1 + 0.8 4.7 + 0.8 * p < .05 Nurses less of laggard attributes than physicians Innovativeness Scores RO1 HS10482

  45. Summary