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between nurse ƐƚĂĸnŐ and quality of care in nursing homes: Evidence-Based Nursing Regulation: A Challenge for Regulators Nancy Spector, PhD, RN These are complex times for regulators on nursing boards, particularly in three areas. First, they must stay abreast of emerging practice issues emanating from technological advances, systems thinking, a more diverse patient population living longer with multiple chronic illnesses, and a national focus on patient safety and error prevention. Second, there has been a national call for the transformation of nursing education (Benner, Sutphen, Leonard, & Day, 2009; Greiner & Knebel, 2003), and nursing boards are seeing increasing numbers of substandard or fraudulent nursing education programs. This adds to the boards’ workload. Third, disciplinary activity involving nurses has increased during the last 10 years (National Council of State Boards of Nursing, 2009), forcing regulators to stay on their toes regarding disciplinary action and investigation. In this challenging climate, the time is ripe to focus on evidence-based regulation as a strategy for making quality decisions related to regulation. Ce www.journalofnursingregulation.com 31 Differentiating Evidence-Based Health Care and Research Utilization Although today’s buzz term is evidence-based health care, in the 1980s and 1990s it was research utilization (Polit & Beck, 2004). According to Titler (2006), research utilization is the narrower term and addresses the use of findings from a study or set of studies in a practical application unrelated to the original investigation. The goal of research utilization is to translate research findings into actual situations. In contrast, the goal of evidence-based practice is to make decisions by using the best possible evidence. Titler (2006, p. 441) points out that although research utilization and evidence-based practice sometimes are used interchangeably, their meanings differ. Evidence-based practice refers to “judicious use of the current ‘best’ evidence,” whereas research utilization is a subset of evidence-based practice because it focuses on the application of research findings. Six Steps of Evidence-Based Health-Care Regulation The six steps of evidence-based health care discussed below resemble those used to develop a systematic review (Pawson, 2006; Sackett et al., 2000). However, the steps have been modified slightly so they are applicable to nursing regulation. Step 1: Formulating the question. The researcher converts the need for information about a regulatory problem into an answerable question. For example, educators might wish to know why they cannot substitute 100% of students’ clinical experiences with simulation. Thus, the researcher might develop the following answerable question: In prelicensure programs, are clinical experiences with actual patients essential for public protection? Step 2: Identifying and collecting evidence. The researcher searches and retrieves published results of studies. This step requires a comprehensive review of databases and websites to ensure that all relevant primary studies have been collected. Step 3: Appraising quality of the evidence. The researcher critically appraises the evidence for its validity and impact, or effect size, and for relevance to the question. Step 4: Processing data. The researcher extracts and synthesizes the data, integrating them with regulatory expertise and the values of public protection. Step 5: Disseminating findings. Results are reported to a wider policy community, and best practices are identified. Step 6: Evaluating effectiveness and efficiency. Continuous quality improvement is conducted in an effort to seek ways to improve steps 1 through 5. Hierarchy of Evidence When appraising research, investigators grade relevant studies according to a hierarchy of evidence. Several hierarchies are used for medical interventions, all of them differing slightly (see Table 2). Randomized controlled trials are not always appropriate for nursing interventions. Therefore, Evans (2003) devised a hierarchy-of-evidence rating system for nursing interventions that also can apply to nursing regulation (see Table 3). Most hierarchies of evidence focus on studies that evaluate the effectiveness of interventions. Evans’ hierarchy also grades studies that evaluate the appropriateness of health care. Studies addressing appropriateness might ask questions such as “Does the consumer view the outcomes as beneficial?” or “What health-care issues are important to the consumer?” Consequently, the range of research methods used in Evans’ hierarchy is broader than in hierarchies that address only effectiveness. In addition, the Evans’ hierarchy grades studies that address feasibility, which focuses on the context of the intervention. Evaluating feasibility is particularly valuable for regulation, as it acknowledges that intentional organizational change is highly complex. Such questions as “What are the required resources?”, “How will it be accepted by consumers?”, and “How should it be implemented?” are asked. Answering these questions requires a broader range of research methods. Researchers adhere to a rigorous scientific methodology when developing systematic reviews, integrative reviews, and meta-analyses on particular topics for health-care professionals. These types of reports all use the steps listed above to
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