Paper #2: Research Utilization Paper (Research/Global Health)

Running head: DIFFERENCES FOUND IN GLOBAL HEALTH 1

Differences between Quality Improvement (QI), Evidence-Based Practice (EBP),

and Original Research Evidence in Global Health

Carla S. Garcia

Nicole Wertheim College of Nursing and Health Sciences

Author Note

Carla S. Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida

International University

Correspondence concerning this article should be addressed to Carla Garcia, Nicole

Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL

33199. Contact: [email protected]

DIFFERENCES FOUND IN GLOBAL HEALTH 2

Abstract

Care can be improved using different forms of scientific inquiry. Either at the clinical practice

level, using scientific knowledge as guidance to clinical decision making; utilizing a more formal

and systematic approach, applying quality improvement, and evidence-based practice; or

participating in original nursing research. Clinical nurses, nurse practitioners, researchers, and

the whole healthcare team should participate in activities that aim to a better practice, facilitating

positive patient outcomes. Such activities work independently but are interrelated, since they aim

for a common result which is the best possible practices that yield to successful patient outcomes

in a holistic manner. In this paper a brief review of the definitions of Quality Improvement (QI),

Evidence Based Practice (EBP), and Research Evidence are presented as well as their differences

and similarities.

Keywords: Evidence-based, practice, quality, improvement, original, nursing research,

client care, patient outcomes, scientific base, clinical expertise.

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Significance and Background

Issues in clinical practice such as the high rate of Catheter Associated Urinary Tract

Infections (CAUTIs), postoperative Deep Vein Thrombosis (DVT), development of pressure

ulcers and/or atelectasis on immobilized patients, etc., should awaken a spirit of inquiry in all

healthcare personnel, especially nurses. In the article “Clarifying the Conundrum: Evidence-

Based Practice, Quality Improvement, or Research?” by Eileen J. Carter, Kari Mastro, Courtney

Vose, Reynaldo Rivera and Elaine L. Larson, nurses’ dynamic participation in clinical

scholarship is required to strengthen the nursing career and improve patient care (Carter et al.,

2017, p.267). Nurses play a critical role in patient care and are consistently applying clinical

judgement to meet clients’ needs in a holistic way; Therefore, nurses’ input is fundamental for

the development of QI, EBP, and original research. These terms serve the same purpose: better

patient care and cost-efficient practices. They do possess some differences; however, they are

interrelated not independent (Carter et al., 2017, p.267).

Quality Improvement

A definition from the U.S. Department of Health and Human Services (2011) stipulates

that quality improvement entails organized and ongoing activities that lead to measurable

development in healthcare services and the health status of targeted health communities (as cited

in Connelly, 2018, p.125). Monitoring and improving quality care are ongoing processes that all

healthcare professionals, including nurses, should participate in. The intend of quality

improvement is to offer the best possible care to patients, therefore, improving healthcare

outcomes. Unlike large research studies, quality improvement work targets smaller populations

utilizing data for a specific organization, such as patients of a certain healthcare facility or

agency. According to the Quality and Safety Education for Nurses (QSEN), nurses are expected

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to utilize data to trace results of care activities and use enhancement techniques to design and test

changes to constantly improve the quality and safety of healthcare systems (as cited in Connelly,

2018, p.125).

One example of quality improvement could be the application of an ground-breaking

statewide quality improvement initiative in Colorado. The Colorado Stroke Alliance (CSA)

demonstrated a tremendous improvement in stroke care through statewide quality endeavors

containing advising, data reporting, and nursing participation (Smith et al., 2009, p.112). One of

the quality improvement outcomes was reported by participating CSA hospitals, indicating that

when using the American Heart Association’s (AHA) Get With the Guideline's Stroke Patient

Management tool (GWTG-Stroke), in grouping with their hospital’s comprehensive quality

efforts, developments in performance can be perceived. Participating hospitals in the Colorado

Stroke Registry have registered nurses as stroke program managers and/or data coordinators

(Smith et al., 2009, p.112). This suggests that nursing involvement is fundamental for the success

of quality improvement programs.

Evidence Based Practice

Evidence Based Practice is a method of utilizing established evidence (research and

quality improvement), resolution, and nursing proficiency to lead the conveyance of holistic

patient care (Boswell & Cannon, 2018). The examination of a vast compilation of research

studies concludes that EBP enhances the quality and safety of healthcare, increases better health

results, diminishes geographic disparities in care, and decreases expenses (Mazurek, 2016). EBP

is viewed as an analytic approach to clinical decision making, that encompasses the most

efficient and current evidence, clinical proficiency, clinical assessment, and consideration of

patient predilections and values within a context of caring (Boswell & Cannon, 2018). In the

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United States, EBP is vital in meeting the Triple Aim in healthcare, which involves the

enhancement of patient experience in care, the improvement of health populations, and a

decrease of the per capita cost of healthcare (Mazurek, 2016).

A key aspect in the development of EBP is to follow seven important steps which lead to

a successful search, implementation, and evaluation of the EBP process. Starting with posing the

problem that is negatively affecting patient care (step 0); formulating the clinical question using

the Patient or Population, Intervention or Interest area, Comparison intervention or group,

Outcome, and Time format (PICOT) (Step 1); conducting an evidence search to answer the

clinical question (Step 2); followed by a quick critical appraisal of a few studies (Step 3);

incorporating the evidence with clinical competence and client predilections and values (Step 4),

employing and assessing change in practice (Step 5); and lastly, consolidating change in practice,

and disseminating the outcomes (Step 6) (Mazurek, Fineout-Overholt, Stillwell, Williamson,

2010, p.51-53).

Original Research Evidence

When clinical or practice situations are not supported by strong evidence that can lead to

a standard, original nursing research comes into play. Original research utilizes statistical

methods to calculate the combination of variables that could yield to better patient care outcomes

(Baker et al., 2014, p.196). Following the scientific method, all research starts by formulating a

hypothesis. In original research, a relationship is hypothesized between variables; nevertheless,

their correlation is unknown. The objective of nursing research is to determine the connection

between these variables and the significance of it. For instance, the need to provide a successful

suicidal risk screening tool in the emergency department can be addressed by performing

research leading to the implementation of a tool that works efficiently in providing a thorough

DIFFERENCES FOUND IN GLOBAL HEALTH 6

suicidal risk assessment. In this case, a relationship between certain patient criteria (subjective

and objective), and the risk for suicide can be found (Baker et al., 2014, p.197).

There are two basic groups that encompass the methods used for directing nursing

research: quantitative and qualitative research. In quantitative research, data is collected

objectively in an ordered, systematic, controlled manner so that the results can be applied to

other circumstances and/or populations (Boswell & Cannon, 2018). Quantitative research utilizes

statistical analysis to validate a hypothesized association among two variables; it includes use of

mathematical models and expresses the connection between variables in a numerical form. On

the other hand, qualitative research generally focuses for an in-depth discernment of the

experiences of others (as cited in Boswell & Cannon, 2018). The researcher reproduces the

socially built nature of reality, the association amid the research and the subject of the research,

and the situational aspects that outline inquiry (Boswell & Cannon, 2018). Groups of qualitative

research comprise phenomenology, grounded theory, ethnography, and case studies. Types of

data gathering include semi-structured and structured interviews, and observation. The results are

then summarized to describe the phenomenon (Baker et al., 2014, p.197).

Discussion

Acknowledging the differences between the three concepts previously presented, allows

nurses to develop a spirit of inquiry. The appropriate application and implementation of theses

methodologies maximizes favorable outcomes (Baker et al, 2014, p.195). For example, QI

projects would be suitable when determining whether the appropriate standards of care are

practiced in a specific clinical setting. The purpose of QI projects is to regulate the execution and

establishment of standards while monitoring the department’s continuous process (Baker et al,

2014, p.195). EBP is used when enough research is available to guide the development of a

DIFFERENCES FOUND IN GLOBAL HEALTH 7

clinical or practice standard, but the research has not been fully adopted in the practice

environment. For instance, EBP can be useful to explore enhanced screening for domestic

violence in an Emergency Department (ED). There is available research on the topic, and its

implementation if of significant importance in the ED setting, but still there is some learning to

do when it comes to its practice in this area (Baker et al, 2014, p.196). Lastly, research

incorporates activities aimed to the exploration of new findings. An example of research would

be a study done by Provonost et al., in which a set of evidence-based strategies such as hand

hygiene before central line insertion, and use of optimal catheter insertion site, were used to

prevent central line infections. The incorporation of these initiatives decreased the rate of central

line infections and has been implemented nationally with great success. In this scenario, the work

of researchers established new findings by determining the influence of a new intervention on

rates of central line infection, leading to higher quality care and outcomes (as cited in Carter et

al., 2017, p.267).

Conclusion

Today’s healthcare environment demands the application of several methodologies in

order to offer high quality care. The application of these methodologies is to be carried out by

members of the healthcare team, particularly nurses. Nurses’ clinical judgement, knowledge of

standard practices in the healthcare setting, and their research inquiry are essential qualities for

QI, EBP, and research. The definition of these activities is not completely clear, and therefore

could be subject to interpretation. For this reason, they may be viewed as separate entities rather

than being interrelated. Quality Improvement aims to reach an improved clinical practice in

healthcare. In order to do so, it compares the current performance through data analysis to meet

the desired standard. The EBP process starts with an inquiry; the inquiry is converted into a well

DIFFERENCES FOUND IN GLOBAL HEALTH 8

formulated question that facilitates research; a few works of research on the topic are selected

and examined; followed by the integration of clinical experience and patient preference; and

finally, the evaluation of outcomes in practice, and dissemination of the established change.

Original Research Evidence presents a more scientific approach, it basically aims to find a

correlation between two hypothesized variables. It utilizes quantitative measurement and

qualitative measurement; the latter focusing on the association between the research and the

subject of the research, and the situational aspects that outline inquiry. Even though noticeable

differences exist, QI, EBP and research aim to a sole purpose: better patient outcomes in clinical

practice.

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References

Baker, K. M., Clark, P. R., Henderson, D., Wolf, L. A., Carman, M. J., Manton, A., & Zavotsky,

K. E. (2014). Identifying the Differences Between Quality Improvement, Evidence-based

Practice, and Original Research. JEN: Journal of Emergency Nursing, 40(2), 195–197.

https://doi.org/10.1016/j.jen.2013.12.016

Boswell, C., & Cannon, S. (2020). Introduction to nursing research: Incorporating evidence-

based practice. Burlington, MA: Jones & Bartlett Learning.

Carter, E. J., Mastro, K., Vose, C., Rivera, R., & Larson, E. L. (2017). Clarifying the

Conundrum. JONA: The Journal of Nursing Administration, 47(5), 266-270.

doi:10.1097/nna.0000000000000477

Connelly, L. M. (2018). Overview of Quality Improvement. MEDSURG Nursing, 27(2), 125–

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