Chapter 7: WOC Nurse's Role in Evidence-Based Practice and Research

Evidence-based care with definable outcomes is the expectation of 21st-century health care consumers. Health care consumers and providers, including agencies such as the Centers for Medicare & Medicaid Services and the health care insurance industry, expect care to be delivered based on the best available research and evidence. Many agencies and groups utilize and publish evidence-based clinical practice guidelines, including the WOCN Society. WOC nurses use all types of research and evidence to influence the quality of patient care that is provided while practicing in the full scope of WOC specialty nursing (ie, direct care, education, research, consultation, and administration). This chapter provides an overview of evidence-based care/practice, discusses the components of evidence-based practice (EBP), describes the process for searching for evidence and how to critically appraise and critique research, discusses how to apply evidence, briefly discusses the role of the WOC nurse in research, and presents information about evidence-based resources available to the WOC nurse.

Development of Evidence-Based Care

There are many roles that a WOC nurse can play in research and EBP, which include the following:

Consumer and developer of evidence-based guidelines and standards of care.
Investigator in a scientific research trial.
Evaluator of products.

The WOC specialty nurse can contribute to the development of evidence-based care in many ways without assuming the role (or responsibility) of a primary investigator such as by participating in the following activities:

Surveys or polls.
Clinical trials or product evaluations (see section on product evaluation).
Data collection for pressure ulcer prevalence and incidence studies or continuous quality improvement projects/studies that relate to WOC care, or foot and nail care.
Data collection for generation of institutional, regional, or national databases that capture descriptive data, such as the following:
- The number of visits required for preoperative and postoperative management of the new ostomy patient.
- The number of visits/cost of supplies necessary to ensure venous ulcer healing in home care patients.
- Quality outcomes when managing urinary or fecal incontinence via behavioral interventions.
Poster presentations (eg, case studies, practice innovation, research).

Evidence-Based Practice

Evidence-based practice is the deliberate use of current best evidence in decision making about patient care. Evidence-based practice is a problem-solving approach that answers key clinical questions that guide patient care. By developing and using evidence for making decisions, patient care is enhanced and satisfaction of the WOC nurse is expanded (Melnyk & Fineout-Overholt, 2010). The components of EBP include the following:

A systematic search and appraisal of evidence to answer the clinical question(s).
Integration of the expertise and experience of the WOC nurse.
Consideration of the patient's preference, values, and concerns.

Evidence-based practice is different from research utilization in that it incorporates the WOC nurse's experience and the patient's preferences, values, and concerns (Melnyk & Fine-Overholt, 2010; Polit & Beck, 2008). “Evidence-based practice requires good nursing judgment; it is not finding research evidence and blindly applying it” (Perry & Potter, 2010, p. 3). Although there are many models and theories about the effective use of EBP in nursing and health care, each model or theory incorporates the critical steps essential to EBP (Melnyk & Fine-Overholt, 2010; Perry & Potter, 2010):

Formulate the compelling clinical question.
Search the literature for the best available, relevant evidence.
Critically appraise the evidence.
Apply the results to clinical practice or the patient situation.
Evaluate the outcomes.

When searching for evidence, it is essential to ask a question that will allow you to find information in a timely fashion. Without a well-formulated question, a search for evidence may lead to an overwhelming amount of information that does not address the clinical question at hand. To search for evidence about a clinical question in the scientific literature, it is suggested to use a PICOT format to state the question (Fineout-Overholt & Stillwell, 2010; Perry & Potter, 2010; Stillwell, Fineout-Overholt, Melnyk, & Williamson, 2010). There are online and print resources that provide education on how to develop PICOT questions such as the article on EBP by Stillwell and colleagues (2010). PICOT is the acronym for the following:

Patient population of interest.
Intervention of interest.
Comparison of interest.
Outcome of interest.
Time.

Reviewing the Literature

After a problem has been identified and the PICOT question(s) formulated, it is necessary to review the literature for supporting evidence. The WOC nurse must be able to perform a literature search, accurately interpret and synthesize the findings, and then implement these findings into clinical practice. The purpose of the literature review will determine the extent of the literature search required. A WOC nurse in a clinical setting would most commonly complete a literature review to support an evidence-based project such as development of policies and procedures, development of standards of care, or application of research into practice in response to a clinical problem (Wound, Ostomy and Continence Nurses [WOCN] Society, 2010).

In a research setting, the WOC nurse would complete an extensive literature review for a research report, proposal, thesis, dissertation, or for a systematic review for development of practice guidelines (Polit & Beck, 2008). The following discussion focuses on performing a basic literature review for an EBP problem or research report. Additional information about conducting literature searches for developing research proposals and writing grants for research funding has been developed by the Center for Clinical Investigation (CCI) of the WOCN Society Foundation and is available at http://www.wocn.org under the Foundation link for research and funding. Additional information about grant writing is available in Chapter 8 and in the sample WOCN Society Member's Research Grant Proposal (Appendix T).

A current systematic review of high quality might be all that is needed to support an evidence-based change in practice to improve patient care, such as a meta-analysis of existing randomized controlled trials (RCTs) about a relevant topic from the Cochrane Collaboration (http://www.cochrane.org). It is also wise to look for recent studies that were published after the systematic review was completed to further support a practice change.

Systematic reviews of current literature might also be found in white papers, best practice documents, and clinical practice guidelines. A thorough review of several nursing databases will help determine if the guideline or best practice document has reviewed the existing body of knowledge related to the clinical question. It is important to note that clinical practice guidelines are based on systematic literature reviews, with the intent to influence clinical decision making to solve practice problems. Guidelines are generally developed when there are gaps in knowledge, so information in the systematic review may vary in the quality of the evidence.

A basic research report or review is an overview of the published evidence with 2 purposes: to provide an overview of current evidence about a problem and to prepare an argument regarding the need for new research (Polit & Beck, 2008). The individual providing the literature review should demonstrate comprehensive knowledge of the topic and/or problem through a well-documented critical appraisal of the research. A review for a research report should be 2 to 4 pages to provide an overview of the body of evidence.

Searching for evidence

When looking for evidence, the strongest scientific evidence is derived from the synthesis and analysis of multiple RCTs. In EBP, weaker evidence is derived from quasi-experimental studies (eg, uncontrolled clinical studies, time series studies), nonexperimental research (eg, descriptive studies such as clinical series, case studies, retrospective chart reviews, observational studies), and published expert opinion. One of the controversies surrounding EBP is determining what evidence is best to support practice. Some advocate using evidence only from RCTs (ie, experimental study designs). Others propose that nurses apply all sources of evidence related to their practice area to develop, implement, and evaluate nursing practice (Waite & Killian, 2008), because using only RCT evidence restricts information about many areas of practice vital to WOC nursing. The WOCN Society (2011) considers multiple levels of evidence in developing clinical practice guidelines and rates research evidence (ie, level I to level VI), according to the criteria provided in Table 7.1.

**Table 7.1. Level and Criteria for Rating Research Evidence**
Level	Criteria
Level I	A randomized controlled trial (RCT) that demonstrates a statistically significant difference in at least 1 important outcome defined by P < .05. Level I trials can conclude that the difference is not statistically significant if the sample size is adequate to exclude a 25% difference among study arms with 80% power.
Level II	An RCT that does not meet level I criteria.
Level III	A non-RCT with contemporaneous controls selected by some systematic method. A control might have been selected because of its perceived suitability as a treatment option for an individual patient.
Level IV	A before-and-after study or a case series of at least 10 patients using historical controls or controls drawn from other studies.
Level V	A case series of at least 10 patients with no controls.
Level VI	A case report of fewer than 10 patients.

Choosing databases

Choosing the correct database to obtain information to answer the clinical question is essential. Well-known health care scientific and medical databases are MEDLINE, PubMed, and CINAHL:

MEDLINE is the National Library of Medicine's premier database. This can be accessed for free through PubMed.
PubMed is a free database accessing citations from MEDLINE, life sciences journals, and other online books. It is maintained by the US National Library of Medicine at the National Institutes of Health.
CINAHL is the Cumulative Index to Nursing & Allied Health Literature. This database is nursing focused and is a membership benefit of the American Nurses Association. It also may be accessed through university libraries and is a good place to start searching for professional nursing standards.

These databases are representative of the scientific knowledge base for health care, medicine, and nursing, but no one database contains all the information of interest to the WOC nurse. There are hundreds of databases available today, many of which are highly specialized (Fineout-Overholt, Berryman, Hofstetter, & Scollenberger, 2010). Therefore, multiple databases should be used for exhaustive literature reviews. A list of Web sites for evidence-based resources is provided in Appendix U.

Critical appraisal

After the literature has been reviewed and the available evidence has been compiled, it is necessary to critique the evidence in a systematic manner. Critical appraisal is a “…systematic process used to identify the strengths and weaknesses of a research article in order to assess the usefulness and validity of research findings” (Young & Solomon, 2009, p. 82). There are several principles of critical appraisal that apply to all types of study designs and various checklists or guidelines are available to assist in the process (Callihan, 2008; Young & Solomon, 2009).

Table 7.2 includes a sample guide that can be used to critically appraise and synthesize individual or multiple research studies (WOCN Society, 2005, pp. 78–79). The guide to performing a research critique is divided into 2 major sections: Title/Abstract and Full Report. You should complete the Title/Abstract section first and then critique the Full Report only if the Title/Abstract section indicates there is adequate value in the report to proceed with a more detailed analysis and synthesis.

**Table 7.2. Guide to Critique Research**
Section	Criteria	Responses		Comments
Title	1. Title is clear and readily understood?	Yes	No
Abstract
	2. Problem is clinically relevant?	Yes	No
	3. Study procedures are clear?	Yes	No
	4. Results are understandable?∗	Yes	No
	5. Findings and/or conclusions are concisely stated?∗	Yes	No
	∗Note that these two criteria (4 and 5) do not ask you to agree or disagree with the results or conclusions of the researchers. Instead, the abstract and title should be clear, concise, understandable, and (most important of all) relevant to WOC nursing practice. Proceed with a critique of the full research report only when the abstract meets the following standard: You respond yes to all 5 of the criteria, or You respond yes to numbers 2, 4, and 5
Full report critique	Having decided that this report is worth a more detailed critique, your analysis should now shift from “yes vs no” to the strength of the evidence provided by this study and its potential impact on your practice. The following questions will lead you to the answers to these essential issues.
Research problem	What clinical problem does this study purport to address?
	What specific research questions or aims are to be answered by the study?
Review of the literature	Remember that the sole purpose of the literature review is to briefly summarize previous research related to this study.
	What are the major 1–3 points summarized in the literature review?
	Do the investigators (authors) omit any critical studies in your opinion?	Yes	No
	Does the literature review provide a current synthesis of evidence related to the problem?	Yes	No
	Does the literature review cite mainly primary sources?	Yes	No
Study methods	Who were the subjects (patients) for this study?
	What was the setting for the study?
	Was the sample size adequate?	Yes	No
	Was a power analysis used to determine the sample size needed?	Yes	No
	Are the participants and the setting similar to my patient population and my setting?	Yes	No
	Does the research design minimize bias and threats to validity?	Yes	No
Instruments	Instruments are defined as all the equipment used to measure outcomes of the study. They include forms filled out by the patient, nurse, or physician; machines used to measure physiologic parameters such as wound size; and qualitative assessments such as severity of pain or infection in a wound.
	What instruments did the researchers use to measure the study outcomes?
	Do the investigators provide evidence that their instruments are reliable and valid?	Yes	No
	Are you persuaded that the instruments are sufficiently reliable and valid to produce reproducible and accurate results?	Yes	No
Results	The results section summarizes the outcomes of the researcher's investigation. Spend time understanding the results as presented. This is the most important section of any research report, but its relevance is sometimes lost because of intimidating tables, figures, and statistical findings. The following questions will allow you to answer basic questions; more experienced research reviewers will focus on statistical analysis.
	Are the research questions, aims, or hypotheses answered in this section?	Yes	No
	Are the results statistically significant?	Yes	No
	Does the author describe limitations to the study design?	Yes	No
	Are the results clinically relevant to WOC nursing practice?	Yes	No
	Did the researchers select the best statistical analysis to answer each research question or aim?	Yes	No
Discussion and conclusion	This section should project the relevance of the data reported in the results section. It must not reach beyond the data reported in the results section.
	Does the discussion focus on the clinically relevant findings of the study?	Yes	No
	Do the authors provide implications for further research?	Yes	No
	Are the implications for further research clinically relevant?	Yes	No
	What 1–3 “bottom-line” conclusions does this study confirm, challenge, or disprove?
	Do the authors conclude that an intervention is effective or safe or both? Remember that safety and efficacy can only be concluded in the context of a randomized clinical trial that is adequately powered and well-designed. A case study or clinical series never proves or disproves safety or efficacy.	Yes	No

Strength of the evidence

As part of the critical appraisal process, it is necessary to be able to discern the level and quality of the evidence. There is no “gold standard” instrument for critical appraisal (Young & Solomon, 2009) Table 7.1 provided the levels and criteria for rating research evidence utilized by the WOCN Society in developing clinical practice guidelines. To classify the strength of the evidence for the recommendations in the clinical practice guidelines, the Society uses 3 levels (ie, level A, B, or C). Table 7.3 includes the level of evidence ratings used for WOCN Society's guideline recommendations (WOCN Society, 2011, Appendix E, p. 7).

**Table 7.3. Level of Evidence Rating for Strength of the Guideline Recommendations**
Level of Evidence Rating	Criteria
Level A	Two or more supporting RCTs of at least 10 humans with the condition under consideration (at level I or II), meta-analysis of RCTs, or Cochrane systematic review of RCTs.
Level B	One or more supporting controlled trials of at least 10 humans with the condition under consideration or 2 or more supporting nonrandomized trials of at least 10 humans with the condition under consideration (at level III).
Level C	Two supporting case series of at least 10 humans with the condition under consideration or published, expert opinion.

Applying the evidence

After the WOC nurse has gathered and appraised all the available evidence to answer the PICOT question, the evidence can be applied to clinical practice. There are various models such as the Stetler model (Romp & Kiehl, 2009; Stetler, 2001) and the Iowa model (Titler et al., 2001) to guide the application of evidence into clinical practice (Ciliska et al., 2010). The WOC nurse should choose a model that fits the practice and philosophy of the institution where the practice change will occur. A full exploration of models of EBP and research utilization is beyond the scope of this chapter, and the reader is encouraged to explore the Web sites for EBP resources in Appendix U for more information about this topic.

Product Evaluation

WOC nurses are recognized for their expertise in clinical matters and their knowledge about product selection for patients with WOC needs. Therefore, they may be offered opportunities to participate in product evaluations. Product evaluations are objective evaluations of products that are approved by the US Food and Drug Administration. The purpose of a product evaluation is to obtain objective data to use for deciding which products should be stocked and used in a particular care setting. Indications for conducting a product evaluation include when the product is to be evaluated:

Has the potential to meet an unmet clinical need (eg, a skin barrier paste that is resistant to urine).
Offers a significant clinical advantage over the product currently in use (eg, a new silicone-based contact foam has an increased absorptive capacity, has secure adhesion without taping the edges, is atraumatic upon removal, and leaves no dressing residue).
Offers a significant cost advantage over the product currently in use (eg, a new mattress replacement system has the same therapeutic features as a specialty bed, but at one-third of the cost).

There are also situations in which a product evaluation is not necessary and it would be appropriate for the WOC nurse to decline to conduct an evaluation such as in the following circumstances:

When the product to be evaluated is not relevant to the WOC nurse's patient population (eg, a compression therapy wrap in a nonambulatory care setting where 95% of the wounds are pressure ulcers on the trunk).
When the product to be evaluated offers no significant therapeutic or cost advantage compared to the product currently in stock (eg, caregivers and patients are satisfied with the current product line and the competitive product offers similar features at a similar cost, but without any additional significant advantages).

Role of WOC nurses in product evaluation

WOC nurses serve as clinical resources for value-driven purchasing and often serve on clinical product evaluation teams. Just identifying good resources to incorporate into practice is not enough in today's health care climate. Clinical knowledge about the product (eg, cost, ease of use, outcomes) must also be applied as part of the product evaluation process.

Risks, benefits, and possible contraindications for use of the products must be considered before pilot trials can begin. Each facility may have specific policies in place for implementing product evaluations. A manufacturer/vendor may assist or facilitate education related to their products and the criteria for the product's use with oversight from the WOC nurse or other designated team members. Professional team members involved in product evaluations should complete an annual disclosure or conflict-of-interest statement to ensure nonbiased evaluations and avoid conflicts.

A guide for product evaluation

Prior to conducting a product evaluation, the WOC nurse should consult the organization's value analysis or purchasing department about the appropriate process/procedures to follow for conducting the evaluation and for obtaining “no charge” products. The following are general guidelines for conducting a product evaluation:

Select the appropriate unit(s) or patient population(s): For example, when evaluating moisture barrier incontinence cloths, the most appropriate setting would probably be a critical care unit or an extended care unit.
Establish clear, objective criteria to be used for the evaluation: Create a simple 1-page form (Figure 7.1) for data collection with structured responses that minimize the time required for completion of the form. The facility may have generic or electronic evaluation forms, which can be customized for the evaluation.
Conduct in-services about the products with nursing and any other departments that will be involved in the evaluation. Include the purpose of the evaluation and the roles and responsibilities of staff for data collection, if applicable. Be sure to include those who may be impacted by the product outside of clinical care (ie, housekeeping, family members, or maintenance).
Compile data on a representative number of patients who would benefit from the product being evaluated. Note: Patient permission is not necessarily required for comparative evaluation of the US Food and Drug Administration–approved products. Consult with the facility's administration and institutional review board for any questions about obtaining patients' permission.
Provide a written summary of the results and make recommendations for integration of the findings into nursing clinical practice. Include the clinical observations throughout the trial, discussions with care providers, and the data that were gathered.
Communicate the trial's outcomes and recommendations to the staff and companies whose products were studied.

Figure 7.1. Sample Product Evaluation Form: Evaluation of a 3-in-1 Incontinence Cleansing Cloth

WOC Nurse Researcher

In addition to synthesizing research findings into EBP and education, the WOC nurse has a responsibility to contribute to the research base through participation in the investigational process whenever feasible. Research is frequently perceived as “impossible” for the average nurse due to the complexity of the process, and limited time and resources. However, roles and opportunities for WOC nurses in research are rapidly growing in health care, academia, and industry settings. The focus of WOC nurse researchers is on advancing the art and science of WOC nursing care (WOCN Society, 2010). Before proceeding with any research endeavor, it is essential to review the institution's policy for conducting research and obtaining informed consent from research participants, and submit the proposal to the institutional review board for approval.

As experts committed to lifelong learning, it is important for WOC nurses to share and improve the current knowledge base in all practice settings. Dissemination of research findings can occur through publication or presentation in a variety of media or formats such as professional journals, poster presentations, Web-based education, or bedside clinical education.

Research and EBP Resources for the WOC Nurse

There are a variety of evidence-based resources provided by the WOCN Society and its CCI of the WOCN Society Foundation that are available online and can be accessed on the WOCN Web site (http://www.wocn.org) in the Member Library (http://www.wocn.org/MemberLibrary), WOCN Bookstore (http://www.wocn.org/Bookstore), and under the Foundation, Research & Funding section of the WOCN Web site (http://www.wocn.org/ResearchFunding). Some of the resources to support EBP and research by WOC nurses include the following:

Spotlight on Research section in each publication of the Journal of Wound, Ostomy and Continence Nursing (JWOCN).
WOCN Foundation Small Grant Program: Annually, offers research funding to a member of the WOCN Society. The CCI administers the grant and provides mentorship and assistance with designing proposals (http://www.wocn.org/ResearchFunding).
Research Grant Proposal Toolkit (http://www.wocn.org/SubmissionToolkit).
Electronic Database Links to aid in exploring current evidence for practice (Appendix U).
Regular publication of research studies in the JWOCN: Print and online access to JWOCN is a benefit to WOCN Society members.
WOCN Society evidence-based clinical practice guidelines, best practice documents, etc. (see Table 7.4).

**Table 7.4. WOCN Society Publications and Documents to Support Research and Evidence-Based Practice by the WOC Nurse**
Product	Description	Type of Evidence	Source
Best Practice Documents	Describes best practices used to address a variety of clinically relevant problems.	Based primarily on expert opinion or nonexperimental research. Content validation is completed to ensure that the content reflects consensus among a national panel of clinical experts.	Developed by WOCN Society committees or task forces.
Clinical Practice Guidelines	Addresses prevalent and clinically relevant areas of clinical practice using a systematic literature review and a qualitative assessment of the strength of the evidence.	Randomized clinical trials and quasi-experimental studies (excludes expert opinion and single-case studies).	Developed by WOCN Society committees or task forces.
Evidence-Based Report Cards	Highly focused questions are addressed using a systematic literature review and a qualitative assessment of the strength of the evidence.	Randomized clinical trials and quasi-experimental studies (excludes expert opinion and single case studies).	Developed by the JWOCN editor and published in the JWOCN.
Position Paper	Describes opinions or a specific stance related to advocacy, or a course of action related to clinical practice.	Committee/task force charged with review of all levels of evidence including expert opinion.	Developed by WOCN Society committees or task forces.
White Paper	Authoritative report of topics or problems of concern to WOC nurses.	Committee/task force charged with review of all levels of evidence including expert opinion.	Developed by WOCN Society committees or task forces.

The Wound, Ostomy and Continence Nursing Certification Board, in collaboration with the JWOCN, publishes an annual EBP literature review supplement that provides a valuable research update and quick reference for busy WOC nurses. The supplement provides a synopsis of current research and trends relevant to WOC nursing, foot care, advanced practice, and advancements in industry and technology. The synopsis includes a brief statement about the clinical practice implications of the study's findings (ie, what does this mean to me and my practice?). The reviews also serve as valuable resources for identifying areas where further research or technologic advancements are needed (Wound, Ostomy and Continence Nursing Certification Board, 2011). Other collaborative or professional resources available to support research and EBPs include but are not limited to the following:

Schools of nursing.
Other professionals within your health care team.
University or college librarians.
Organizational research committees.
Research collaboration with colleagues.
Other professional organizations.
Journal or research groups (ie, groups of clinicians who meet to share, discuss, and critique research).
Sigma Theta Tau.

References

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