Getting Best Outcomes: Paradigm and Process Matter.

First, let me clarify that this editorial is level VII in the intervention hierarchy of evidence and is intended to foster thought and dialogue. That being said, please read through the information provided here and consider the questions asked and the offered points to ponder. Recently, I was in a good conversation (those that actively address challenging issues without the usual political trappings) about the purpose of research in which a colleague offered the thoughtful question, “Is the purpose of all research to improve practice?” After discussion and reflection, we agreed that it is indeed. Whether the research is theory development, qualitative inquiry, intervention trials, or cohort studies about populations, systems or individuals, all are focused on improving outcomes. This, along with other good conversations, prompted consideration of the underpinning framework of healthcare decision-making in practice and in education. According to education and practice standards, the framework is evidence-based decision-making (EBDM; American Association of Colleges of Nurses [AACN], 2008; Greiner & Knebel, 2003). From other good conversations, I have learned that EBDM means different things to different clinicians. For the purposes of this editorial, I am considering EBDM as what is depicted in Figure 1. Before this framework can universally drive practice decision-making, we must consider what is required to understand how to engage this framework to ensure that all clinicians can use it. First, consider the primary worldviews that underpin thinking in health care—evidence-based practice (what do we already know to guide us?), research (let’s do a study to tell us), and tradition (that’s the way we’ve always done it). In this editorial, we will focus on evidence-based practice (EBP) and research, since tradition is a sacred cow that should be put out to pasture. One of the first issues is the language involved in these worldviews. Though the terms used in research and EBP often are the same, they can be confusing and off-putting to clinicians who do not have command of this language. Terms such as evidence, randomized controlled trial, case-control, systematic review, outcomes, implementation, and confidence interval are but a few that may need clarification. A glossary of terms is a good idea to have while everyone is mastering EBP or research language. Once clinicians understand the language, this barrier to actualizing EBDM as the worldview for health care can be removed. To further explore these two worldviews, consider how language can identify which paradigm drives decision-making. Here are two examples that may be helpful: (a) do professional development or performance appraisals include language about generating research studies as a primary goal, or do they require outcomes or impact from evidence translated into practice (i.e., made standard of care); and (b) does the language within organizational goals reflect research-generation or EBDM? It follows that a predominance of research generation language and guidelines in organizational documents and processes indicates a research worldview as decision driver. In an educational example, consider that evaluation methods can reflect the worldview from which the course is taught. If assignments are focused on how research is generated and not on how it is used, then research is the driving worldview. Also, course titles reflect the current worldview. Consider that there are numerous nursing programs that have a course in their baccalaureate programs entitled, “Nursing Research” and others that have a single course entitled, “Evidence-Based Practice”; however, few have courses entitled “Evidence-Based DecisionMaking” or have EBP threaded or integrated throughout the curricula. As mentioned earlier, mandates shaping healthcare education require adeptness in EBP as an essential competency for health professionals’ education and translation of evidence into professional nursing practice as standard care (AACN, 2008; Greiner & Knebel, 2003). These mandates have provided a foundation for the shift in worldview of practice and education decision-making from research generation to EBP (i.e., EBDM). It is a wonderful time to have language across all documents and processes follow. The next area to consider is methods of each worldview. Evidence-based practice and research both have rigorous methods, that when followed systematically, result in valid and reliable outcomes. The research process is taught in a general way in primary as well as secondary education. In nursing, we have built our profession on strict adherence to the research process (Table 1). A research study is not well received, and rightfully so, if the research process has not been followed. For example, a randomized controlled trial must have certain methodological steps addressed within its design. If those steps are not followed, there is a judgment that must be made about the validity of the research—it is not trustworthy. The same is true for its reliability of findings. Within EBDM, sustainable improvement (change)—the outcome of EBP—requires the EBP process to be systematically followed (Table 1). From the literature, there are few examples of strict adherence to the process (Magers, 2013). Many have tried to adhere to the EBP process, but have not