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Population Health for Nurses

11.1 What Is Evidence-Based Decision-Making?

Population Health for Nurses11.1 What Is Evidence-Based Decision-Making?

Learning Outcomes

By the end of this section, you should be able to:

  • 11.1.1 Describe evidence-based decision-making in public health.
  • 11.1.2 Describe the steps of evidence-based decision-making.
  • 11.1.3 Explain the importance of evidence-based decision-making in public health.
  • 11.1.4 Identify tools to support evidence-based public health decision-making.

Health care is designed to help enhance the quality of life for clients through preventative care, maximization of development, care of acute illness, and guidance toward death. Health care providers should use the most up-to-date information on care and treatment plans in these efforts. Evidence-based public health (EBPH) uses the best available current research and information to make decisions that encourage health promotion, disease prevention, and health maintenance. Comprehensively, “EBPH involves accessing the best available research to inform decisions, systematically using data and information systems, applying appropriate frameworks in program planning, engaging the community in assessment and decision-making activities, evaluating the program, and disseminating lessons learned to key stakeholders” (Ruebush, 2019, p. 1). Evidence-based decision-making (EBDM) is an essential element of EBPH. A key part of effective practice is applying evidence-based information.

EBDM is similar to evidence-based practice (EBP), yet each has its nuances for use in nursing. EBP uses the best available research, clinical experience, and client preferences to inform client-care interventions and evaluation. EBDM is the process of using the most recent research and clinical practice experience to make optimal decisions regarding a policy, practice, and/or program. Foundationally, EBDM extends from EBPH as they both consider the context of the community in conjunction with found evidence to identify and implement appropriate interventions. Additional considerations in the EBDM process include community partner buy-in, feasibility, cost-effectiveness, sustainability, health equity, and public sentiment.

Use of Evidence-Based Decision-Making

Public health is a sector of health care that seeks to protect and enhance the health of people and the communities in which they live, work, and play. Public health decisions and initiatives can have a broad impact, so it is important that they direct health care providers to use the most efficient and effective practices to promote the best possible results. Public health decision makers use EBDM to methodically determine which interventions work best in public health and then share this information with clients and other health care professionals.

The following are fundamental characteristics of EBDM that nurses and health care providers must consider (Cincinnati Children’s Hospital Medical Center [CCHMC], 2023):

  • Using the best available peer-reviewed information to make decisions
  • Using multiple forms of evidence
  • Systematically utilizing data and information systems
  • Employing program planning frameworks
  • Optimizing community participation in decision-making and assessment, followed by a comprehensive evaluation
  • Providing learned information to affected individuals and decision makers
  • Implementing successful communication, scientific methods, common sense, and political concerns throughout each step

The National Collaborating Centre for Methods and Tools (NCCMT) has outlined seven steps in the evidence-based decision-making process in public health. Figure 11.2 breaks down these steps—define, search, appraise, synthesize, adapt, implement, and evaluate—to describe the process of EBDM.

A diagram shows seven steps in the evidence-based decision making process, with an arrow from one step to the next. The steps occur in the following order--Define: Cleary define the question or problem. Search: Efficiently search for research evidence. Appraise: Critically and efficiently appraise the research sources. Synthesize: Interpret information and form recommendations for practice. Adapt: adapt the information to the local context. Implement: Decide whether and plan how to implement the adapted evidence into practice or policy. Evaluate: evaluate the effectiveness of implementation efforts to determine if the program or plan was delivered as intended or achieved the anticipated result. After the Evaluation step, an arrow points back to the Define step.
Figure 11.2 The National Collaborating Centre for Methods and Tools (NCCMT) has outlined seven steps in the evidence-based decision-making process in public health. These steps include define, search, appraise, synthesize, adapt, implement, and evaluate. (See National Collaborating Centre for Methods and Tools, 2023a; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Defining the Problem

The first step in the EBDM process is to clearly define the concern, the problem or question that needs to be addressed. Questions to consider in this step include:

  • Who is the target group?
  • Which problem or problems need to be solved?
  • What is the anticipated plan to implement necessary changes?

The concern is generally formatted as an answerable PICOT question. A PICOT question frames the problem in terms of the affected population, the proposed intervention, the groups in the population that will be compared to determine the effectiveness of the intervention, the outcome being studied, and the time frame in which the study will take place. Table 11.1 presents the breakdown of a PICOT question.

P Population Outlines the client or client population affected by the problem and with whom the nurse will be in contact. Populations may be defined in multiple ways, some of which include the following:
  • General population: population as a whole
  • Specific community types: rural or urban dwelling
  • Population-based descriptors: age, socioeconomic status, risk status, demographics, or literacy levels
I Intervention Refers to the change or treatment that will be implemented for the outlined client (population).
C Comparison Outlines the reference groups for whom the population in question will be compared. This would be a comparison for the chosen intervention.
O Outcome The result that the project will be studying or evaluating.
T Time The time interval in which this project will take place, such as when and for how long the intervention will be in place and then compared to the outlined control group.
Table 11.1 PICOT Question Breakdown

Identifying each component of a PICOT question helps to clearly define the problem. This question then guides the literature search and the steps in EBDM in public health. As noted, the population may include individuals, communities, or a larger population group. The nurse must decide if the population will be further defined, such as by age, literacy level, or socioeconomic status. Interventions may involve a specific change or treatment, or they may test an approach to health not previously used or studied in this specific population with the outlined concern. The comparison may be a different intervention, often the one currently in practice, or the absence of the proposed intervention. Outcomes will contain measurable results or the aftermath of the implemented intervention. Time outlines how long the intervention will be in place and/or how long outcomes will be measured. Table 11.2 provides example PICOT questions as well as the breakdown of the elements for each question.

Examples Population Intervention Comparison Outcome Time
Do early intervention programs provided between 14 and 16 years of age prevent underage drinking among adolescents who live in rural areas within the United States? Adolescents in rural areas within the United States Early intervention programs No early intervention programs Prevent underage drinking 14–16 years of age
For adults over age 60, does a daily 20-minute exercise regimen reduce the risk of hypertension compared with no daily exercise regimen over 3 years? Adults over age 60 20-minute daily exercise regimen No daily exercise regimen Risk of hypertension 3 years
Are women ages 18–25 years who use intrauterine devices (IUDs) for contraception at an increased risk for developing blood clots compared to women 18–25 years who use oral contraception over 5 years? Women ages 18–25 years IUD contraception Oral Contraception Risk for blood clot development 5 years
Table 11.2 Example PICOT Questions

Searching the Literature

The next step in the process, searching, involves reviewing the literature to examine what research is available to address the defined concern and additional data points, which should consider the population in question. A clearly defined question guides nurses’ evidence search. Where to Find Evidence-Based Interventions will further discuss potential sources. Public health may utilize both qualitative and quantitative data or information as they both may apply to this subset of health care, and both may be used to help answer questions in public health. Quantitative research contains numbers and objective data to evaluate outcomes and determine results. Quantitative data are expressed by amounts in numerical terms. Often in public health, this is epidemiologic data. Qualitative research deals with nonnumerical data such as experiences, attitudes, and behaviors. Qualitative data are expressed in word form, cannot be quantified, and describe perspectives of individuals and populations. Another option for seeking information is a focus group. Focus groups are interviews conducted with small groups of participants who share similar traits or interests that will inform the current problem or issue in discussion. These groups are often used to gauge health beliefs, evaluate programs, and provide information fitting the needs assessment.

A community needs assessment is an appraisal that identifies a community’s strengths and resources. The needs assessment gives reviewers a quick overview of existing systems and policies and areas that need improvement or additional resources. Assessment, Analysis, and Diagnosis covers conducting a community needs assessment in more detail. Often a windshield survey is part of the community assessment. This is the process of observing the community while driving or walking through it to obtain a visual overview. Creating a Healthy Community discusses windshield surveys in more detail. An additional part of this needs assessment is identifying any possible community partners. Community partners are those individuals or organizations who are impacted by the project’s evaluations and outcomes and thus are interested in the process. While selecting search modalities, health care providers should consider all public health angles, such as issues in the community context, community and political actions and preferences, research, and public health resources. These link closely with the NCCMT model for evidence-based decision-making (see Where to Find Evidence-Based Interventions). Finally, public health nurses may also obtain information regarding a population’s morbidity and mortality rates through the National Vital Statistics System. Public health care providers may also utilize public health surveillance to obtain data. The four types of broad categories for public health surveillance are noninfectious health conditions, infectious diseases, both infectious and noninfectious diseases and health conditions, and risk factors and exposures (Centers for Disease Control and Prevention [CDC], 2023a).

While searching the literature, nurses must seek data that note the experiences and requirements of marginalized communities. Since research and scientific work are driven, and thus inhibited, by the perspectives and biases of those who conduct the work, there are notable communities and populations that lack accurate representation within studies, scientific theories, policies, and fact statements. To gather accurate information regarding these marginalized communities, nurses should utilize disaggregated data, or data that has been further broken down into subcategories, such as gender or race, to evaluate health inequities. Additionally, nurses must have a full understanding of the social determinants of health and how these apply to the root causes of inequitable health care access and availability. Ultimately, to identify disparities that may go otherwise unnoticed, data should be analyzed from an intersectional vantage point that recognizes the interdependence of different social identities such as gender, race, ethnicity, age, religious beliefs, developmental abilities and disabilities, and socioeconomic status.

Appraising the Literature

While a significant amount of published research may be available for any given concern, the studies may not be of equal quality. Critically appraising, or assessing each study for relevance and credibility, is necessary to ensure the information provided is meaningful, trustworthy, and relevant. Literature that is meaningful will be useful in some way and/or produce important information. Information is considered trustworthy based on its confirmability and the reviewer’s confidence in the believability of the information produced in the literature. Finally, relevance considers how pertinent the evidence is to the current problem and population. While there may be literature and evidence that provide valuable information, if the information is irrelevant to the topic in discussion or does not consider similar circumstances for the population, it may not be useful or applicable. This appraisal step should help nurses and other health care providers determine if the methods used in the selected studies or data points are strong enough to use in the problem-solving process. Once each source has been appraised for validity and then reviewed, the information can be synthesized. Where to Find Evidence-Based Interventions in this chapter will further discuss where to find evidence-based interventions, and Evaluating the Quality of the Evidence will discuss evaluating the quality of evidence.

In addition to appraising research articles themselves, all other forms of data should be appraised accordingly. Depending on the population, problem, and resources available, some sources may hold a greater weight based on the specific topic and community in question.

Synthesizing the Data

Synthesizing the data involves compiling the information to determine what the research says about the concern. The nurse synthesizing the articles and other data points should consider overlapping themes or messages from different sources. If the research offers conflicting messages, referring back to the appraisal step will be helpful in determining which may be more trustworthy or applicable to the current project. The research that the appraisal process determines to be of the highest quality should hold more weight in decisions. Additionally, in this step, health care providers should synthesize the information gathered from other data sources to identify common themes or attributes of the community or client.

Adapting the Information

The adapting step of this process involves determining if this synthesized information can apply to the client (which may be a single person, a family, a community, or a population). In population health, the client is often a community or a whole population, and therefore interventions must work broadly. Referring to the synthesizing step, the nurse should identify actionable steps as possible interventions. In the adapting stage, nurses should consider whether these interventions will be successful or relevant to the client in question and/or if the intervention will need adaptation to work efficiently. Components to consider are the identified problem, the identified intervention, the level of client (single person, family, community, or population), and any other affected individuals that need to be considered, such as organizations or partners in the process. An intervention that is successful in one community may not be successful in another community. Community and population attributes should be considered to determine applicability across clients. These should be considered and discussed during the dissemination phase of the project. Limitations or additional factors to consider should be discussed to help others determine if the intervention(s) can be applied to their specific population.

Implementing the Intervention

The implementation stage involves acting on the information and carrying out the determined plan after a possible intervention or action is identified and brainstorming has taken place regarding how this may need to be adapted to the client in question. In this step, public health nurses will identify actionable and tangible steps for the process. In the public health sector, these often include changes in practice, programs, or policies. This may mean revision of the previously designed practice, program, or policy or delivery of a new version of these components. Client characteristics are crucial at this step as they drive how interventions may be implemented.

Thinking back to the appraisal step, recall that interventions that seem optimal based on research may not be the best option for the current problem. For example, literature might state that frequent time away or vacation would benefit the mental health of teens and young adults. Yet this population may have limited financial means or transportation that make this intervention less feasible. While multiple pieces of evidence may support an intervention, a public health nurse can use their expertise to determine whether an intervention is appropriate for a specific population. If this is discussed in the adapt stage, it may be possible to alter aspects of an intervention to meet the needs of the local context.

Evaluating the Effectiveness of the Plan

Evaluation, the final step in this process, entails determining if the plan accomplished what was intended and, if not, what may need to be changed moving forward. The previously determined indicators are used as an objective measurement of success for the project. Once the effectiveness has been reviewed and evaluated, the team may then determine if they should continue with the intervention(s) as designed or adjust them based on the evaluation.

Theory in Action

The Importance of Evidence in Decision-Making

The NCCMT has created the video “Using Evidence in Public Health Decisions: Why It Matters” to emphasize why using evidence-informed decision-making is essential in public health.

Watch the video, and then respond to the following questions.

  1. How does EBDM impact financial decisions regarding implementation of health interventions?
  2. Discuss how EBDM can help build the relationship between health care providers and the public.

(See NCCMT, 2017.)

Additionally, the information should be disseminated for use by other health care providers or systems. An essential step in all health care research is sharing results to benefit the population as a whole. Sharing information within the nursing community increases the scope of knowledge within the field and helps to ensure all parties stay up-to-date with policies, practices, programs, and interventions. This may also optimize the cost and quality of care by sharing what has or has not worked in the past. This eliminates multiple steps of trial and error regarding the same topic.

Unfolding Case Study

Part A: Evidence-Based Decision-Making

Read the scenario, and then answer the questions that follow.

Recall from the beginning of this chapter that Amari and Milo have noticed an increased rate of anxiety in teens within their community and that the interventions they have used previously are not eliciting the same results. To efficiently identify possible interventions for this population, they know their best option is to use evidence-based practice strategies and that they must first draft a PICOT question as the foundation for their EBP project.

Amari and Milo develop the following PICOT question: Does daily exercise have an impact on anxiety rates in adolescents compared to those who do not engage in daily exercise over 3 months?

1.
Which of the following components must be covered to be an effective PICOT question?
  1. Population, interest, cost, outcome, time
  2. Population, intervention, comparison, outcome, time
  3. Price, interest, comparison, overhead, time
  4. Price, intervention, company, outcome, time
2.
In the PICOT question developed by Amari and Milo, which of the following is the proposed intervention?
  1. Anxiety rates
  2. Adolescents
  3. Daily exercise
  4. 3 months

Importance of Evidence-Based Decision-Making

The intent of health care is to ultimately improve client outcomes with the goal of providing the most effective care available. The EBDM process increases the objectivity of public health decision-making. Historically, health care treatments and skills relied on wisdom passed from one person to another in the form of anecdotes and demonstrations, which may be unreliable. This informal transmission of knowledge, skills, and treatments exemplifies a 19th-century technique that American surgeon William Stewart Halsted called “see one, do one, teach one” (Ayub, 2022). Following this philosophy, nurses should see a skill or technique being completed by another nurse, perform this skill or technique themselves, and then teach a less experienced nurse how to do the skill as needed. While this technique has been relatively effective historically, and while the nursing field as a whole is based on collaboration and knowledge sharing, the technique has flaws. If the original nurse did not perform the skill safely based on the most recent evidence, any nurses who learned the skill from the original nurse would follow the same unsafe pattern. For example, if the first nurse demonstrating insertion of a peripheral intravenous line chooses to rip the finger off their glove to touch the vein site after cleaning the identified site, each subsequent nurse may follow this unsafe process, increasing infection risks to all clients moving forward based on this inappropriate protocol. Similarly, the “see one, do one, teach one” technique relies on each nurse’s memory and the efficacy of each nurse who follows, leading to many opportunities for subjective error. Furthermore, this practice is more difficult to implement on a larger scale such as public health nursing where there is often not an opportunity to directly view the application of a skill.

EBP and EBDM are objective and concrete methods for finding relevant information and applying it to a particular problem. In public health, EBDM is used to ensure that interventions are supported by data and thus should be effective and that they reach the intended population (CCHMC, 2023). It also considers the available resources within the community. The EBDM process provides a compelling rationale for a course of action, whether that action is the continuation of an existing practice or the adoption of a new intervention. The process is thorough and can be replicated. According to NCCMT, evidence-based decision-making in public health should consider research, community health issues (with local context), community and political preference and actions, public health resources, and the public health expertise of decision makers (NCCMT, 2023a) (Table 11.3). Though there may be more steps involved in EBDM than in historic methods of teaching and decision-making, it enables the nurse to use informed and objective data to make the best and safest decision for the client (Erwin et al., 2020).

Public Health Expertise Sources of Evidence
Decision makers use their public health expertise and consider evidence from these sources:
  • Available public health resources
  • Community and political preferences and actions
  • Available research findings
  • Community health issues and the local context
Table 11.3 Evidence-Based Decision-Making (See NCCMT, 2023a.)

Theory in Action

Evidence-Informed Decision-Making

The video “NCCMT - URE - Evidence Informed Decision Making - A Guiding Framework for Public Health” presents an overview of the EIDM model. It examines the five overlapping ovals depicted in the model as types of evidence used to inform decision-making. The video uses the example of respiratory illness rates to show how two communities might use other sources of evidence to reach different evidence-informed decisions.

Watch the video, and then respond to the following questions.

  1. How might health inequities impact the research phase of the evidence-based decision-making process?
  2. Discuss how the unique sources of evidence discussed in the model overlap with one another and with public health expertise.

(See NCCMT, 2018.)

Tools to Support Evidence-Based Decision-Making

Multiple resources and tools are available to assist health care providers in using EBDM. To effectively use these tools and resources, it is necessary to have a strong foundational understanding of the specific client, from a single person up to a whole population. Though much of the information will be gathered from research, to align interventions, these tools must also connect to the designated population and the identified concern for them to prove valuable in the decision-making process. Some tools and resources are designed to support clinical decisions, while others are aimed at working through the EBDM process.

Clinical decision-making support tools are formatted as resources in which health care providers can quickly look up information on clinical practices, assessments, diagnostics, and treatments. One example is UpToDate, which focuses on point-of-care utilizing EBP to make recommendations (Wolters Kluwer, 2023b). This user-friendly, broadly accepted tool provides information for all subspecialties of internal medicine. Another available tool is Lexicomp, which houses detailed drug information in real time (Wolters Kluwer, 2023a). These tools can help health care providers at all levels make and discuss clinical decisions to determine what is currently in practice and help determine what may need to change.

Just as there are support tools available to facilitate clinical decisions, many tools are available to assist with the multistep process of EBDM. Some of these tools help determine a searchable question, while others help with the organization and categorization of identified research articles. Resources to help users define the problem focus on turning the identified concern into an answerable question and identifying key terms to guide an efficient search. Search tools are available to help users sift through data points and document results to track trends and highlighted usable factors. Tools for the appraisal step allow users to organize the data and appraise them accordingly. These tools have prompts and helpful formatting templates to keep appraised information organized. Synthesizing tools then help users pull out relevant information from their search and appraisal process. Adapting tools helps users evaluate the evidence for applicability and usability regarding their current concerns. Approaching the tactical aspect of the process, implementation tools help users plan for and carry out implementation based on their specific circumstance. Finally, evaluation tools and resources provide checklists of key aspects of EBDM and how to review the process that has taken place, starting with defining and moving through implementation (NCCMT, 2023b). To complete the process, there are tools to help with the reflection process of the evaluation phase. For example, McMaster University’s Health Evidence website has multiple tools specifically designed for this process in the public health sector.

Tutorial: How to Use healthevidence.org

McMaster University’s Health Evidence website offers tools for evidence-informed decision-making. Examples of tools include an EIDM checklist, a resource guide, a search tracker, and search strategies for developing a PICOT question.

Watch the video, and then answer the following questions.

  1. What are the three main methods for searching within Health Evidence?
  2. Health Evidence utilizes sources at which level of evidence to evaluate the effectives of public health interventions? Why is this evidence leveling important?
  3. What rating system is used in this database?

By utilizing these tools, nurses and other health care providers can make the complex process of EBDM more attainable by breaking these steps into manageable tasks.

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