Ava 154-157 PDF - Critical Thinking, Research, and Quality Improvement

## Section VI: Critical Thinking, Research, and Quality Improvement ### A. Critical Thinking * **Definition:** Intellectual discipline that actively and skillfully analyzes, assesses, evaluates, and synthesizes each element of a situation. * **Aspects of "well cultivated" critical thinking:**...

## Section VI: Critical Thinking, Research, and Quality Improvement ### A. Critical Thinking * **Definition:** Intellectual discipline that actively and skillfully analyzes, assesses, evaluates, and synthesizes each element of a situation. * **Aspects of "well cultivated" critical thinking:** * Achieve awareness of thought * Active effort to address each element of a situation * Develops and utilizes purposeful thinking * Applies elements of reasoning to a problem or situation * Thinks open-mindedly, recognizing and assessing individual assumptions and implications * Communicates effectively with others to determine solutions to complex situations or problems * Projects and determines consequences of actions. * **Elements of thought:** * **Point of View:** Individual orientation/perspective * **Purpose:** Individual goals/objectives * **The Question:** Problem or issue * **Information:** The facts, data * **Interpretation:** Conclusions, solutions * **Concepts:** Laws, principles, theories * **Assumptions:** Presuppositions, "taking for granted" * **Consequences/Implications:** The outcome * **Attributes of critical thinkers:** * Open-mindedness * Actively pursues the truth * Exhibits patience and confidence * Engages in self-reflection * Demonstrates the courage to acknowledge and correct errors * Exhibits a neutral perspective * Possesses keen observation skills * Accepts criticism * Displays good communication skills * Accurately documents findings and actions. * **Considerations for critical thinking in healthcare:** * Critical thinking is identified as both a skill and an attitude * Critical thinking is a process. * Improves patient care delivery * Prevents medical error through projection and determination of consequences * Facilitates the selection of the most appropriate vascular access device to meet patient needs * Takes into consideration the patient's entire clinical picture and not just one aspect. ### B. Research * **Statistics terms:** * **Incidence:** Occurrence of new cases of disease or injury in a population over a specified period of time. * Some epidemiologists use "Incidence" to indicate the number of new cases in a community, others use incidence to mean the number of new cases per unit of population. * **Incidence Proportion:** Proportion of an initially disease-free population that develops disease, becomes injured, or dies during a specified (usually limited) period of time. * Synonyms include attack rate, risk, probability of getting disease. * **Incidence Rate:** Incidence rate or person-time rate is a measure of incidence that incorporates time. * Example: The number of central line infections that occur in one year. * **Prevalence:** The number of cases, both old and new, present at a point in time in a defined population. * Example: 10% of patients in the ICU have positive blood cultures during the stay. * **Morbidity:** Rate at which an illness or abnormality occurs, calculated by dividing the number of affected people in a group by the entire number of people in the group. * Example: Morbidity of diabetes is 30% among hospitalized patients. * **Mortality:** Death rate reflecting the number of deaths per unit of population in a specific region, age group, disease, or other classification * Example: In 2010, an estimated 46,000 deaths occurred from breast cancer in American women. ### C. Research Design * **Qualitative:** Describes and explores phenomenon within a context * Process focused * Usually small study population * Data collection continues until data saturation occurs (occurs when the researcher no longer hears or sees new data from the population) * Qualitative Data (eg, interview transcripts): Are evaluated for themes * Qualitative Methodologies: Phenomenology, content analysis, grounded theory * Example: Modes of thought and feelings of pediatric nurses who care for dying children. * **Quantitative:** Describes relationships, cause and effect. * Outcome focused. * Sample size (study population) varies depending on what is being studied. ### D. Evidence-Based Practice (EBP) * Incorporates the best available evidence with the expertise of the clinician and the preferences of the patient in the context of care delivery. * Considered the "gold standard of care" in medicine, nursing, and other health care disciplines. * Evidence in health care can be used as the basis for: * Defining healthcare processes (i.e., patient assessment, care planning, care delivery) * Policy and procedure development and revision * Creation of patient care management tools (i.e., protocols, clinical pathways, etc.) * Care of an individual patient. * **Barriers to evidence-based practice:** * Lack of organizational culture and readiness for EBP * Lack of EBP mentors and champions * Inadequate EBP knowledge and skills * Clinician fails to appreciate the value of EBP * Large amount of available information and literature * Contradictory research findings * Patient expectations and demands * Conflicting priorities (workload may impair time for research) * Ability/lack of clinician's authority to initiate practice changes * Environments supportive of EBP * Training and educational support are provided. ### Study types * **A power analysis (statistical method)** is used to determine optimal sample size to answer the research question. * **Data collection continues until** the desired sample size is achieved. * **Descriptive Statistics:** Include measures of central tendency (mean, median, mode) and measures of variability about the average (range and standard deviation). * **Inferential Statistics:** Statistical tests that test hypotheses and relate findings to the sample or population. * **Example of Quantitative Study:** Comparison of two skin preparation procedures for peripheral venipuncture * **Randomization** * **Randomized Studies:** A study in which there are two or more interventions and study participants are allocated at random (by chance alone) to receive one of these interventions. * **Randomized Controlled Studies:** A study in which participants are allocated at random to receive one of several interventions, and one of these interventions is the standard of comparison or control. * **Non-Randomized Studies:** A study in which participants are not assigned by chance to different intervention groups. Participants may choose which group they want to be in, or they may be assigned to the groups by the researchers. * **Effect size:** The difference between the groups studied, a measure of strength of the relationship between two variables. * **One factor used to determine necessary sample size:** Large effect size increases the probability of statistical significance and power. * **Meta-Analysis:** A method of summarizing and synthesizing results of findings accumulated from a variety of sources and studies. * **Combines results of several studies on one topic into one large study with many participants.** * General aim is to more powerfully estimate the true "effect size" as opposed to a smaller "effect size" derived in a single study under a given single set of assumptions and conditions. * Considered more informative than any one of the included studies in the analysis considered alone. * **Meta-analysis of randomized controlled trials is statistically stronger than analysis of any single study.** * **Cohort studies:** A type of research that compares large groups of individuals to investigate causes or links to diseases or certain clinical outcomes. * **Retrospective cohort studies:** Look at data that already exists and was not collected for the purpose of the study. Researchers are not able to guide the exact information being collected or go back and gather any missing data. * **Prospective cohort studies:** Planned in advance and therefore require collection of new data. * **Evaluating research reports:** * Read and critique the entire study * Examine the significance of the problem * Determine if the literature review is current and complete * Review the study design and study population and determine appropriateness to research question being posed * Identify strengths (i.e., randomized controlled study) and limitations of the study (e.g., conducted at one institution) * Review findings and their interpretation; have inappropriate generalizations been made? * Determine the feasibility of replicating the study, is the study presented in enough detail to be replicated? * Review the usefulness of the findings to practice, do the study findings justify or support a change in clinical practice? * Review references for age, cited works older than 5 years may be considered outdated. **Figure:** A pyramid showing the hierarchy of evidence, with "Expert Opinion" at the bottom and "Systematic Reviews" at the top. The pyramid shows that systematic reviews are considered the strongest form of evidence, as they combine results from multiple randomized controlled trials. The pyramid also shows that as you move down the pyramid, the evidence becomes less strong.