Johns Hopkins Nursing Evidence-Based Practice Thrid Edition: Model and Guidelines

(^6) Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines, Third Edition
Quality improvement is a process to improve healthcare services, systems, and
processes at the local level (i.e., unit, department, organization) with the intent to
improve outcomes (U.S. Department of Health and Human Services, 2016). QI
generally includes a method of measuring a particular outcome, making changes
to improve practice, and monitoring performance on an ongoing basis. QI may
uncover a practice problem that initiates an EBP project. Some examples of QI
initiatives are decreasing catheter-associated urinary tract infections, decreasing
wait times in the emergency department, decreasing falls among patients, de-
creasing surgical site infections, improving patient satisfaction, improving pneu-
mococcal and influenza immunization rates, and decreasing restraint use.
Research is a systematic investigation (quantitative, qualitative, or mixed meth-
ods) designed to develop, uncover, create, or contribute to new knowledge that
can be generalized for broader application (U.S. Department of Health and Hu-
man Services, 2009, 45 CFR 46.102[d]). It is often undertaken when no evidence
is found during an EBP project. Research involves approval by an institutional
review board. Some examples of research are investigating pain in the ventilated
patient; communication between caregivers, family, and patient at the end of life;
and post-stroke memory function.
An EBP project is undertaken when clinicians have a particular concern or ques-
tion about their practice. The EBP process includes identifying a practice problem
and EBP question, locating the best available evidence, appraising the strength
and quality of evidence, and synthesizing findings leading to translation of evi-
dence into practice. One example is performing mouth care every four hours on
ventilated patients because the evidence shows that it helps decrease the inci-
dence of ventilator-associated pneumonia and mortality, cost, and length of stay.
A second example is using warm-water compresses to manage nipple pain in
breastfeeding mothers.
While these three forms of inquiry are distinct, they are linked when determin-
ing a course of action based on the nature of the question or problem raised by
nurses. As depicted in Figure 1.1, a frontline nurse raised the issue of increased
infection rates in orthopedic patients with traction pins. Initially, efforts to de-
crease rates began as a QI project. On studying the current practice using the
PDSA method, the team discovered that there was variation in pin care among