Community and Quality of Life: Data Needs for Informed Decision Making

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In contrast, an overarching facilitator of EIDM is a supportive organizational culture that includes nursing leaders championing EIDM work through mentorship and participation in strategic visioning to support frontline EIDM uptake [ 20 , 24 ]. Proposed organizational strategies to encourage EIDM implementation include the explicit addition of EIDM indicators to appraisal processes for practitioners [ 22 ], development of EIDM practice standards [ 25 ], and use of clear EIDM competencies specific to general class nurses and those in advanced practice [ 23 ].

Establishing clarity, consistency, and a rigorous assessment method for EIDM competence provides clear direction for knowledge and skill development, in addition to competence recognition providing further motivation for EIDM engagement [ 26 ]. Given this, competence assessment serves a critical role in sustaining and improving EIDM implementation among nurses.

The focus on assessment of competence and continuing competence i. Critical attributes of EIDM competence are articulated across the literature.


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EIDM knowledge refers to an understanding about the defining theoretical, practical concepts and principles of EIDM, and the different levels of evidence [ 31 — 35 ], whereas EIDM skills are universally understood as the application of such knowledge to perform EIDM tasks [ 31 — 35 ]. Tilson et al. The enactment of EIDM steps in a real-world clinical setting e. Measures assessing individual EIDM competence attributes separately exist in different healthcare disciplines including nursing [ 36 ], allied healthcare [ 37 , 38 ], and medicine [ 39 , 40 ].

However, while the intent of the review was to focus on a population of nurses and midwives in clinical environments, its included studies, to some extent, did include samples of medical practitioners and allied health professionals. Leung et al. Also noteworthy is the inclusion of research utilization measures in the review by Leung et al. Conceptually, the difference between EIDM and research utilization is well articulated in the literature [ 41 , 42 ].

Research utilization encompasses a component of, and is housed under the broader definition of EIDM [ 41 — 43 ]. The critical difference between these concepts involves the form of evidence applied to healthcare practice. While, EIDM denotes use of a broader understanding of evidence that includes integration of not only research, but also evidence from clinical experience, clients and caregivers, and local context or environment [ 44 ]. Despite this conceptual difference, measures originally developed to assess research utilization were still included in the review if their use in subsequent studies was cited as measuring EIDM.

Data extraction also did not include healthcare setting e. Coupled with this, assessment of validity evidence was guided by the traditional Trinitarian approach of treating criterion, content, and construct validity as separate entities [ 45 ], rather than using the contemporary approach of understanding validity evidence as a unified concept according to the Standards for Educational and Psychological Testing [ 46 ]. Not having a comprehensive assessment of validity evidence for a measure in relation to a specific population and healthcare setting would make it difficult to determine appropriateness given a particular context.

As such, the proposed systematic review aims to address these limitations within the existing literature and contribute to a current understanding about the state of evidence in EIDM competence assessment in nursing. The objectives of this systematic review are to 1 comprehensively identify existing measures of EIDM competence attributes i. The contemporary understanding of psychometric assessment will be guided by the Standards for Educational and Psychological Testing [ 46 ].

Narrative synthesis of this data, coupled with identification of practice settings and sample population, will provide a current understanding of existing EIDM competence measures to assist healthcare institutions in determining relevant and robust measures for use in specific nursing practice settings. A comprehensive search strategy was developed in consultation with a Health Sciences Librarian. Search terms will differ according to unique subject headings in each database. Date limitations will be from until the current date. Strategies for locating gray literature will include contacting experts in the field of EIDM competence assessment; searching gray literature databases including ProQuest Dissertations and Theses, Greylit.

Duplicates will be removed and all unique references will be screened for relevance. Studies will be included if they meet the following criteria: 1 study sample consists entirely of nurses or a portion of the sample comprises nurses for which data is presented separately or can be extracted; 2 take place in any healthcare setting e. Studies will be excluded based on the following criteria: 1 they include measures of EIDM competence used among healthcare professionals other than nurses and nursing specific data is not reported separately or cannot be extracted; 2 the full sample or a portion consists of undergraduate nursing students and data for practicing nurses is not reported separately or cannot be extracted; and 3 measures that solely evaluate research utilization defined as only one component of EIDM.

Two independent reviewers will screen references at the title and abstract level using the aforementioned inclusion criteria. From these results, full-text articles will be assessed independently by two reviewers using more detailed screening inclusion criteria. If consensus cannot be met, a third team member will serve as an arbitrator to decide on final inclusion or exclusion. The number of studies identified from information sources, screened for eligibility, included in the review, and excluded studies with reasons identified will be presented in a flow chart using PRISMA guidelines [ 47 ].

DistillerSR will be used to screen citations, upload references, and document reasons for study inclusion or exclusion. Data extraction will be conducted using a predetermined online data extraction form. The form will be piloted independently by two reviewers on five randomly selected references, discussed, and revised as needed following the pilot.


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  • One reviewer will independently extract data pertaining to study characteristics. Thereafter, a second reviewer will check study characteristic data for accuracy. Two reviewers will independently extract data relating to the primary outcomes consisting of the psychometric properties of measures, which include evidence for acceptability, reliability, and validity. Acceptability refers to how acceptable it is for an individual to complete an instrument and will be assessed by extracting data on the proportion of missing responses and time to complete the instrument [ 48 ].

    Data extraction pertaining to evidence of reliability and validity will be guided by the Standards for Educational and Psychological Testing [ 46 ]. Reliability is defined as the consistency of scores from a measure across repeated measurements of different circumstances [ 46 ]. Reliability evidence to be extracted may be presented in the form of standard errors of measurement, reliability or generalizability coefficients, or test information functions based on item response theory [ 46 ].

    As such, a measure cannot be identified as being valid or not valid, rather, validity is a property of the interpretation of test scores [ 49 ]. Producing a strong validity argument to support the interpretation of test scores requires an accrual of various sources of validity evidence [ 46 , 49 ]. Therefore, data extraction as it relates to validity will focus on different types of evidence based on test content, response processes, internal structure, and relations to other variables.

    To assist with extracting data from study results that support validity evidence based on relations to other variables, tables will be developed with established theoretical and empirical literature that can be used as guidelines. These tables will be used as guides to determine support for or against validity evidence for a particular measure in which agreement by both data extractors on these decisions will be required.

    Any discrepancies in data collection will be resolved by consensus between the two reviewers. If during extraction information is incomplete or missing, attempts will be made by one reviewer to contact publication authors and obtain further information. If consensus is not achieved, a third team member will serve as arbitrator for final decisions. DistillerSR will be used by reviewers to document data extraction. Evidence of acceptability, reliability, and validity will be presented narratively. A summary of acceptability findings will be reported for each separate measure.

    Reliability findings will also be reported for scores of each measure according to the different categories i. In synthesizing validity evidence data, other reviews have developed their own system of classifying measures according to various levels [ 35 , 50 ] or by assigning scores [ 51 , 52 ] based on the number of validity evidence sources for scores of a particular measure.

    To follow suit, measures will be categorized into four groups, based on the number of validity evidence sources established across studies e. The groupings will help identify the state of validity evidence for scores of each measure, contributing to an understanding about the psychometric performance of measures.

    Along with psychometric data, study characteristics will also be presented with regard to population and healthcare setting. While this study features a comprehensive search strategy and rigorous systematic review methodology, the authors acknowledge a limitation with respect to quality assessment of primary studies. Such assessment has varied widely across previous psychometric systematic reviews.

    Commonly, modified versions or components of the original COnsensus-based Standards for the selection of health Measurement INstruments COSMIN [ 53 ] have been used to critically appraise single studies in systematic reviews focused on measuring EIDM among allied healthcare professionals [ 31 , 54 ]. An updated COSMIN risk of bias tool was developed [ 55 ] and applied in a recent systematic review of self-report measures for alcohol consumption [ 56 ]. This is an important consideration as the context of patient-reported outcome measures differs critically from that of the proposed study focused on measures of EIDM competence among healthcare professionals i.

    McKenna et al. Other methodological quality assessment criteria such as the CanChild Outcome Measures Guidelines [ 57 ] have also been used in previous reviews [ 34 ]. Although, its original purpose was to support rating the adequacy of childhood disability measures. Testing for evidence of validity or reliability has also not been reported with respect to this tool. While, critical appraisal in the review by Leung et al.

    Across all existing measures i. All measures employ a Trinitarian understanding of validity and assess quality of the study or measure only as it pertains to criterion, construct, and content validity [ 45 ]. This proposed study, however, is guided by a modern perspective of validity established in the Standards for Education and Psychological Testing [ 46 ] which posits that validity is a unified concept, and all types of validity evidence i.

    This approach requires an assessment of all evidence across studies to rate validity, and such cannot be determined until all data on validity evidence is extracted and synthesized. Given this, methodological quality assessment after data extraction is not appropriate. As such, this review instead, will focus on the synthesis of validity evidence in reference to the strength of a validity argument using a classification approach based on the number of validity evidence sources established similarly applied in other reviews [ 35 , 50 ].

    Despite limitations of the proposed study, there is critical contribution to the field of EIDM in nursing practice.

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    The narrative synthesis resulting from this review will present important data on measure characteristics, such as population, healthcare setting, and EIDM competence attributes, in addition to the psychometric properties of validity evidence, reliability, and acceptability; this is largely missing from previous psychometric systematic reviews on EIDM measurement.

    The comprehensiveness of this synthesis facilitates easy selection or determination of relevance for nursing leaders or individual nurses that are seeking a relevant and robust measure to use in their unique practice setting. The authors would like to acknowledge the assistance of Ms. No external funding was received for this study. EB developed the initial manuscript draft. All authors reviewed the manuscript, provided feedback, and approved the final draft for submission.

    Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Emily Belita, Email: ac. Jennifer Yost, Email: ude. Janet E. Squires, Email: ac. Rebecca Ganann, Email: ac. Trish Burnett, Email: ac. Maureen Dobbins, Email: ac. National Center for Biotechnology Information , U. Journal List Syst Rev v. Syst Rev. Published online Nov 3. Jennifer Yost 2 M. Author information Article notes Copyright and License information Disclaimer. Corresponding author.

    Received Apr 20; Accepted Oct Additional file 4: Screening criteria. Abstract Background There are growing professional expectations for nurses to engage in and develop competence in evidence-informed decision-making EIDM due to opportunities for improved client and community outcomes and provision of the highest quality of care. Methods The search strategy, developed in consultation with a Health Sciences Librarian, consists of online databases, contacting experts, hand searching reference lists, key journals, websites, conference proceedings, and grey literature.

    Discussion This systematic review will provide a current understanding about the state of evidence with respect to EIDM competence measures in nursing to assist in determining potentially relevant and robust measures for use in different nursing practice settings. Electronic supplementary material The online version of this article Background Evidence-informed decision-making EIDM is defined as a process in which high quality, available evidence from research, local data, patient and professional experiences are synthesized, disseminated, and applied to decision-making in healthcare practice and policy [ 1 , 2 ].

    Objectives The objectives of this systematic review are to 1 comprehensively identify existing measures of EIDM competence attributes i. Search strategy A comprehensive search strategy was developed in consultation with a Health Sciences Librarian. Inclusion criteria Studies will be included if they meet the following criteria: 1 study sample consists entirely of nurses or a portion of the sample comprises nurses for which data is presented separately or can be extracted; 2 take place in any healthcare setting e. Exclusion criteria Studies will be excluded based on the following criteria: 1 they include measures of EIDM competence used among healthcare professionals other than nurses and nursing specific data is not reported separately or cannot be extracted; 2 the full sample or a portion consists of undergraduate nursing students and data for practicing nurses is not reported separately or cannot be extracted; and 3 measures that solely evaluate research utilization defined as only one component of EIDM.

    Study selection Two independent reviewers will screen references at the title and abstract level using the aforementioned inclusion criteria. Data extraction Data extraction will be conducted using a predetermined online data extraction form. Data synthesis Evidence of acceptability, reliability, and validity will be presented narratively. Discussion While this study features a comprehensive search strategy and rigorous systematic review methodology, the authors acknowledge a limitation with respect to quality assessment of primary studies.

    Conclusions Despite limitations of the proposed study, there is critical contribution to the field of EIDM in nursing practice. Additional file 4: 15K, docx Screening criteria. Acknowledgements The authors would like to acknowledge the assistance of Ms. Availability of data and materials Not applicable. Notes Ethics approval and consent to participate Not applicable. Consent for publication Not applicable.

    Competing interests The authors declare that they have no competing interests. Contributor Information Emily Belita, Email: ac. References 1. Evidence-informed Decision-making. Accessed 20 March Worldviews Evid-Based Nurs.

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    Measuring the effectiveness of mentoring as a knowledge translation intervention for implementing empirical evidence: a systematic review. The effectiveness of knowledge translation interventions for promoting evidence-informed decision-making among nurses in tertiary care: a systematic review and meta-analysis. Implement Sci. Predictors of evidence-based practice implementation, job satisfaction, and group cohesion among regional fellowship program participants.

    Strout T. Strout, T. Curiosity and reflective thinking: Renewal of the spirit. An element was counted as present if mentioned at all, however briefly. Elements were counted as present whether offered by the patient or the physician. These audiotapes were recoded by another coder who was blinded to the results of prior coding. Five percent of the audiotapes were selected at random intervals throughout the coding period and coded twice by the same coder to assess coder drift and intrarater reliability. Descriptive analysis focused on the completeness of informed decision making for each decision, which was determined by using criteria for completeness for the corresponding decision category.

    If all the required elements for the relevant decision category were discussed, informed decision making was considered complete. If none of the required elements were present, then informed decision making was labeled absent. To apply less stringent standards for completeness of informed decision making, we repeated the analysis of completeness using the 2 modifications described above, analyzing all decisions regardless of complexity by the PAR definition and by the all-basic definition. We used 2-tailed t tests to compare the mean number of decisions for primary care physicians and surgeons.

    We compared completeness of informed decision making between primary care physicians and surgeons using a 2-tailed Fisher exact test. We reviewed audiotapes. We analyzed audiotapes, which contained decisions. Participants' demographic characteristics have been presented in detail elsewhere. Compared with primary care patients, those seeing surgeons were slightly younger, more often white, slightly more educated, and of higher socioeconomic status. The number of years since graduation from medical school ranged from 12 to 41 years.

    On average, primary care physicians reported spending 45 hours per week with patients, surgeons reported 58 hours per week. Primary care physician visits lasted a mean of The most frequent medical problems were hypertension, depression, diabetes mellitus, gastrointestinal tract disorders, and musculoskeletal problems.

    Visits with surgeons lasted a mean of For orthopedic surgeons, the most common reasons for visits were shoulder disorders, acute knee injuries, and fractures. For general surgeons, the most common reasons included breast disease, abdominal hernia, and cholecystitis or cholelithiasis.

    The majority of encounters had 3 or fewer clinical decisions There were Most decisions were initiated by the physician The most common types of decisions for primary care physicians were medication decisions For surgeons, the most common decisions were follow-up appointments Overall, surgeons made more decisions than primary care physicians and , respectively. However, primary care physicians made more decisions per visit on average than surgeons. The mean number of decisions per visit for primary care physicians was 2.

    Furthermore, there was a significant difference in the distribution of decision complexity between the 2 groups. Primary care physicians made more intermediate decisions than surgeons Overall, the completeness of informed decision making was low. When examined across all decision categories, few decisions 9. Completeness of discussion of decisions varied by decision complexity. Whereas Within the basic category, there was variation in the proportion of decisions that were complete.

    For instance, There was substantial variation across categories in the frequency with which individual elements were discussed range, 1. Patients were often told the nature of the intervention basic, Physicians rarely explored whether patients understood the decision 0. The extent of discussion consistently increased with decision complexity Figure 1.

    We found a statistically significant increase in the frequency of discussion of individual elements when we compared basic with complex decisions. The most striking increases were in alternatives 5-fold increase , pros and cons fold increase , and uncertainties fold increase. We reanalyzed completeness using the PAR criteria described earlier and found the proportion of complete discussions overall was lower 3. Compared with the initial analysis, completeness was lower in the basic category 0. Discussions of complex decisions were much more frequently complete by this definition, We reanalyzed completeness of informed decision making using the all-basic criteria.

    This analysis sets the moral minimum for completeness, applying the least stringent criteria for basic decisions to all decisions regardless of their complexity. Although this improved the overall proportion of complete decisions, fewer than 1 in 5 decision discussions The proportion of complete decisions improved in both the intermediate Considering the low interrater reliability for elements 5 and 6, we also reran the initial analysis for completeness excluding these elements.

    The results remained largely unchanged with 0. Our focus in this analysis was on decisions rather than individual visits. However, when analyzing decisions by specialty, surgeons had a higher proportion of completeness in informed decision-making discussions than primary care physicians. For basic decisions, When all decisions were analyzed using the PAR criteria, 3.

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    Finally, when all decisions were analyzed by the moral minimum of the all-basic criteria, surgeons still had a larger proportion of completeness in informed decision making Length of visit and length of relationship were not significantly associated with completeness in informed decision making for primary care physicians or surgeons. In this study, we set out to determine the completeness with which physicians involved patients in routine, but important, clinical decisions in office practice. We analyzed these discussions with criteria that sought to balance an ethical ideal with practical reality by taking into account important differences in decision complexity.

    We found that surgeons and primary care physicians in office practice infrequently had complete discussions of clinical decisions with their patients. These findings suggest that the ethical model of informed decision making is not routinely applied in office practice. This low level of informed decision making suggests that physicians' typical practice is out of step with ethical ideals.

    There are practical implications of this missing practice. Inadequate efforts to foster patient involvement in decision making may impair the patient-physician relationship. Furthermore, there are quality-of-care concerns, since there is mounting evidence that inadequate patient involvement may interfere with patient acceptance of treatment and adherence with medical regimens. Noting the minimal levels of completeness across decision categories, we decided to reanalyze the data using modified standards.

    These additional analyses also address the concern that our evaluation sets too high a standard for decision making. Though these analyses PAR and all-basic revealed modest improvement in overall completeness of informed decision making, primary care physicians and surgeons frequently made decisions without discussing the intervention with the patient or seeking their involvement.

    By the most minimal definition consistent with an ethical framework, decision making in clinical practice may fall short of a basic level of patient involvement in routine decisions. The examples in Table 1 and Table 3 illustrate the minimal nature of the discussions that physicians conducted in the audiotapes. In general, surgeons had more completeness of informed decision making than primary care physicians.

    Surgeons have more experience in obtaining written consent for surgery, which may carry over into being more accustomed to discussing other decisions with patients. A recent study of patient-surgeon communication demonstrates that surgeons spend almost half of their visit time educating and counseling patients, significantly more than primary care physicians in this type of conversation. Our model of informed decision making represents a usable framework for involving patients in decision making. Although some patients may wish for more discussion of a particular decision than our model requires, we used a minimal standard for communication.

    Any particular instance of a decision could become more complex, depending on questions and concerns of both patient and physician. Our model emphasizes patient understanding and explicit discussion of the patient's role in decision making, in part so that patients are given a clear opportunity to expand the nature of the discussion to fit their needs.

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    Our model's sliding scale further prevents the physician from being saddled with the onerous task of having lengthy involved discussions about every clinical decision. Finally, the model maintains a critical link to the ethical foundations of informed decision making, and thereby balances the ideal of theory with the reality of practice. There are some limitations to this study. As a cross-sectional study, we do not have the benefit of observing the patient-physician relationship over time.

    Some of the conversations involving decisions may be incomplete because the physician and patient are quite familiar with each other's values, information needs, and decision-making style. Only longitudinal studies of patient-physician decision-making interactions will lay this issue to rest. However, even within a long-term relationship, we argue that our moral minimum would still hold in which the physician at least describes the intervention and solicits patient input before proceeding. In addition, the physicians who participated in this study were mostly white and male, which could limit the generalizability of these findings.

    Also, the quality of decision making may have improved since the time the data were collected in Although there has been increasing interest in patient-centered care, its impact on practice remains unknown. Because we developed and used a new method for audiotape analysis, it is important to demonstrate that this method is valid and reliable. We believe that our method is a valid characterization of communication in the area of decision making. The method was derived from a synthesis of theoretical constructs about ideal informed decision making and bolstered by iterative group discussions between clinicians and laypersons.

    Furthermore, the consistent trends in patterns of overall completeness, with completeness increasing with decision complexity despite different definitions of complete, provides further evidence of the validity of our method. The low reliability of elements 5 and 6 limits our findings only minimally because the majority of decisions were basic, requiring neither element 5 nor 6.

    As we discovered, completeness for intermediate and complex decisions also remained largely unaffected by the exclusion of these elements. Most other studies of informed decision making have examined patient recall, patient reports of adequacy of discussion, or analysis of informed consent forms. While there is no evidence in the literature that audiotape recording of visits influences communication, it is likely that any influence it may have would lead to more discussion around decisions as opposed to less.

    For too long, informed consent in clinical practice has been influenced by an interpretation of informed decision making as a legal obligation in which the emphasis is full disclosure, rather than an ethical obligation toward mutual decision making by fostering understanding. Furthermore, most emphasis has been on informed consent for invasive procedures or participation as a research subject. Turning attention to decision making in office practice reveals that this emphasis has not created a positive model of informed decision making that is relevant and achievable in clinical practice in which the majority of decisions are less than complex.

    Promotion of the patient's understanding, thereby fostering informed participation, is the essence of informed decision making. A new conception of informed decision making can provide a framework for evaluating the adequacy of current practice, as we have illustrated in this study. It can also serve as a framework for developing skills and behaviors that enhance communication and trust, thereby improving the patient-physician relationship and increasing the potential for the beneficial outcomes that will follow.

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    Table 2. Table 3. Table 4. Table 5. Table 6. Table 7. Transparency: informed consent in primary care.


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    Hastings Cent Rep. Google Scholar. Two models of implementing informed consent. Arch Intern Med. Advancing the cause of informed consent: from disclosure to understanding. Am J Med. Do patients want to participate in medical decision making? What role do patients wish to play in treatment decision making? Informed consent: a study of patient reaction.

    Disclosure and informed consent: does it matter how we tell it? Health Educ Monogr.



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