HOW TO MOVE EVIDENCE-BASED PRACTICE; A MODEL TO IMPLEMENT CHANGE Mary Therriault, R.N., M.S. November 15, 2012

OBJECTIVES Identify some of the questions and framework needed to move evidence-based practice (EBP) into nursing practice  Describe some of the sources and references of information for the implication of evidence-based practice  Define the global perspective and use of models of evidence-based practice  Describe some strategies of implementation of evidence-based practice using the Quality and Safety for Nurses 

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NURSING RESEARCH PRIORITIES IN US IN 2000

Reference: http://www2.kumc.edu/instruction/nursing/RTaunton/Article/fall2000/Nursing%20knowledge%2021st% 20century.pdf

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WHAT IS - EVIDENCE? 

Anything that provides material or information on which a conclusion or proof may be based; used to arrive at the truth,used to prove or disprove the point at issue



Using the best available information to answer clinical questions in order to improve practice

(Webster)

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EVIDENCE-BASED PRACTICE Evidence-Based Practice: Conscientious, explicit and judicious use of current best evidence with clinical expertise, and patient values to make decisions about the care of patients (Sackett, 2000)  Evidence-Based Nursing Practice: is the process of shared decision-making between practitioner, patient and significant others, based on research evidence, the patient’s experiences and preferences, clinical expertise, and other robust sources of information 

(STTI , 2007) 5

EVOLUTION OF EBP • •

1998 – Evidence-Based Nursing journal debuted 1999 – The UK Department of Health stipulated that, to enhance the quality of care, nursing, midwifery, and health visiting practice must be evidence-based

•

2002 – The Joint Commission (TJC) begins requiring monitoring of evidence-based core measures

•

2004 – World Views on Evidence-Based Nursing

•

2004 – AACN began publishing “Practice Alerts” 6

WHAT IS THE 1ST STEP TOWARD EBP FOR THE PRACTICING NURSE?  



Asking good clinical questions

Nurses must be empowered to ask critical questions in the spirit of looking for opportunities to improve nursing care and patient outcomes Risk-taking environment 7

KEY QUESTIONS TO MOVE EBP INTO NURSING PRACTICE     

What methods are used by leading/benchmark, organizations Do the findings of recent research suggest an alternative method Are organizational barriers inhibiting the application of best practices in this situation Is there a review of the research on this topic Are there nationally recognized standards of care, practice guidelines, or protocols that apply 8

KEY QUESTIONS

TO MOVE EBP INTO

NURSING PRACTICE      

Why have we always done “it” this way Do we have evidence-based rationale Or, is this practice merely based on tradition Is there a better (more effective, faster, safer, less expensive, more comfortable) method What approach does the patient (or the target group) prefer What do experts in this specialty recommend 9

STEPS IN THE EBP PROCESS Developing a well-built question  Finding evidence-based resources to answer the question  Evaluating the strength and applicability of the evidence  Applying the evidence to practice  Evaluating the effects  Foster culture of lifelong learning  Regularly evaluate for flexibility, accessibility and impact on clinical outcomes 

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WHERE TO BEGIN. . . . 

  

Once we agree upon the question that poses an opportunity for improvement, then we must find the evidence Where should we look Are all forms of evidence equivalent in quality Finding the time, access, and research expertise that are needed to search and analyze the evidence to find answers to their clinical questions  

Don’t reinvent the wheel If other experts have reviewed the evidence on your topic … start there 

Reference: http://www.aacn.org/wd/cetests/media/ci1931.pdf  http://www.hcmarketplace.com/supplemental/3737_browse.pdf 11

EDUCATORS ROLE   

 

EB Education for EB Practice Base educational content on evidence Seek the most current forms of evidence, e.g. journals & online sources vs. texts Encourage students to question and challenge Teach research content in a manner that is interesting and useful 12

MANGERS/ ADMINISTRATION'S ROLE  

   



Encourage inquisitive minds Promote risk-taking and flexibility in the clinical environment Incorporate EBP activities into performance evaluations Provide time & resources – unit internet access Provide support personnel Empower staff to make EB practice changes Acknowledge and reward EB improvements

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VALUES AND PREFERENCES EBN - integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities …

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LOCAL VS. GLOBAL EVIDENCE  Institutional/Local

> National/International Consumer Price Index (CPI) Data/Research Results  Standards & Protocols/Practice Guidelines  Expert Advice 



Patient/Family Preferences

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GLOBAL PERSPECTIVE 

A New Global Perspective of EvidenceBased Wound Protocols Ayello and Sibbald presented at the Third World Congress of World Union of Wound Healing Societies in 2008  Asking for volunteers to rate the Appraisal of Guideline Research & Evaluation (AGREE) Instrument 

Reference: http://www.nln.org/facultyprograms/fac ultyresources/toolkit_facprepglobexp.pdf;



Reference: http://www.ncbi.nlm.nih.gov/pubmed /17008804

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RESOURCES TO SUPPORT EVIDENCE-BASED PRACTICE Government agencies  State agencies  Cochrane Collaboration  Professional Organizations  Benchmark Institutions  Associations 

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WELL KNOWN RESOURCES

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COCHRANE COLLABORATION

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Link: http://www.cochrane.org

HURRICANE SANDY NEXT?

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AHRQ –AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

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NATIONAL GUIDELINE CLEARINGHOUSE

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MODELS OF EVIDENCE-BASED PRACTICE AND IMPLEMENTATION OF CHANGE

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IOWA MODEL Successfully implemented since 1994 internationally  Infuses research into practice to improve quality of care  Planned change principles integrate research and practice  Utilizes a multidisciplinary team approach  Utilizes feedback loops 

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EBP PROJECT: FOLLOWING THE IOWA MODEL 

Step 1: Identify Triggers 

QI data, clinician observations trigger a “Burning Question”

Step 2: Form a Team  Step 3: Review the Evidence 



Find the evidence in research studies or Clinical Practice Guidelines

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EBP: FOLLOWING THE IOWA MODEL 

Step 4: Is there Sufficient Evidence to Change Practice? If Yes:  Select Outcomes  Collect baseline data  Implement 

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EBP: FOLLOWING THE IOWA MODEL 

Step 5: Evaluate the Practice Change Is it working?  What are the outcomes? 



Step 6: Share the Information 

Let others know of your findings and expand the scope 

Reference: https://uiowa.qualtrics.co

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USING THE IOWA MODEL St Josephs Hospital Health Center in Syracuse NY implementing a Critical Care Pain Observation tool using the Iowa Model  PICO question is pain documentation in the nonverbal adult ICU patient better quantified using the current tool versus another toll that could potentially be more behaviorally objective?  Great read. . . . . . . 



Reference: http://www.nysna.org/images/pdfs/communications/jo urnal/spg_smr10.pdf 28

STETLER MODEL First developed in 1976 refined in 1994 and updated in 2001  Five phases: 

    

Preparation Validation Comparative evaluation/Decision making Translation/Application Evaluation

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APPLYING THE STETLER MODEL IN STAFF DEVELOPMENT STEP BY STEP  Preparation:

Using PICO format

P –Population: New nurses orienting to an acute care unit  I – Intervention: Education for preceptors  C- Comparison: Current practice of minimal preceptor education  O – Outcome: Increased job satisfaction of the new nurse 

Reference: http://www.nursingcenter.com/_PDF_.aspx?an=001246 45-200911000-00002

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VALIDATION AND COMPARATIVE EVALUATION 

Validation: 



Yielded five research articles supporting the topic of preceptor education

Comparative Evaluation/Decision Making 

Evaluation if findings were desirable and feasibale to apply to practice 

Taking into account risks, resources and readines of staff decision to hav staff members who precept would atten and intial preceptor education program

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TRANSLATION AND EVALUATION 

Translation 

Translating the results into a plan and then implementing it 



Multiple way of communication the program were used

Evaluation 

Three methods were used Summative evaluations of each class  Changes in job satisfaction  RN turnover rates 

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OUTCOMES Improvement of new orienteer‘s satisfaction with their preceptors  3.95 drop in turnover rate 



Reference: http://www.nccmt.ca/registry/view/eng/83.html

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OTHER RESOURCES

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AHRQ MODEL EVIDENCE-BASED RESOURCES

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Link: http://www.ahrq.gov/about/nursing/nrslinks.htm

AHRQ EVIDENCE REVIEW

Reference: http://www.ncbi.nlm.nih.gov/books/NBK26 72/

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SMALL RURAL HOSPITAL EBP MAKING A DIFFERENCE 

Evidenced-based safe medication practices 

Findings; Hospitals with pharmacist on site more then five hours per week adopted safe medication practice  Approximately 1,800 hospitals with fewer then 50 acute care beds  Reference: http://www.unmc.edu/ ruprihealth/Pubs/Issue Brief2008-1.pdf 

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EBP: PUTTING SACRED COWS OUT TO PASTURE 

Article based on two presentations on EBP from American Association of Critical Nurses 2009 and 2012 National Teaching Institute    

  

Trendelenburg position for hypotension Use of rectal tubes to mange fecal incontinence Gastric residual volume and aspiration risk Restricted visiting policies Nursing interventions to reduce urinary track infection associated infection Used o cell phone in critical care area Accuracy of assessment of body temperature 

http://www.aacn.org/wd/cetests/media/c1123.pdf

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CENTER TO CHAMPION NURSING IN AMERICA 

Center to Champion Nursing in America is an initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation. The Center, a consumer-driven, national force for change, works to increase the nation’s capacity to educate and retain nurses who are prepared and empowered to positively impact health care access, quality, and costs.

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Link: http://championnursing.org

QSEN OVERALL AIM  To

alter nursing’ professional indentify formation so that when we think of what it means to a respected nurse, we think not only of care knowledge, honest and integrity. . . but also knowledge and commitment to quality and safety competencies  QSEN aims to assist Nursing educators who are eager to discover effective ways to promote student learning that will prepare them for becoming full partners in the work of improving patient safety and healthcare systems 

Reference: http://www.qsen.org/overview.php 40

PATIENT-CENTERED CARE 

Classroom: 



Attempt to find assignments that address concepts health literacy, generational preferences and culture

Healthcare Setting: 

Specific education packets, have staff develop case studies, explore cultures of current or past clients



How care has been provided: 



Listen to the client demonstrate respect and compassion

Changes to how care provided: 

Client and family are full partners in coordinated care with respect for preferences 41

TEAMWORK AND COLLABORATION 

Classroom: 



Schools looking for opportunities for interprofessional courses and activities

Healthcare Setting: Inter-professional day or fair  Community project 



How care has been provided: 



Work side by side in performing nursing skills

Changes to how care provided:   

Open communication Shared decision making Inter-professional teams

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EVIDENCED-BASED PRACTICE 

Classroom: 



Review of one EBP guidelines such as pressure ulcer

Healthcare Setting: Workshop related to EBP questions PICO  Unit specific practice review of the evidence example: dressing changes for pressure ulcers 



How care has been provided: 



Use of current hospital policies

Changes to how care provided: Current evidence  Involve clients and families 

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QUALITY IMPROVEMENT 

Classroom: 



Case study, concept maps using the QI cycle, plan, do, study, act

Healthcare Setting: Unit specific QI issues and team following PDSA cycle  Leadership involvement 



How care has been provided: 



Use of nursing policies and protocols

Changes to how care provided: 

Report of how the policy is adhered to and what needs to change input from the team using them 44

SAFETY 

Classroom: 



Focus on specific near miss or adverse event such as medication

Healthcare Setting: 



Unit specific Root Cause Analysis of a near miss or adverse event

How care has been provided: 



Safety for one client at time

Changes to how care provided: 

Look to systems and process to protect populations

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INFORMATICS 

Classroom: Creative ways to assess gap such as typing, word processing  Insuring infection prevention while using EHR







Healthcare Setting: Simulation with EHR use  The challenge of talking to a client not looking at computer screen  How are the keyboards cared for 

How care has been provided: 



Paper tools, accurate

Changes to how care provided: Decision making tools imbedded in EHR  Trends and knowledge sharing 



Reference: mainenursepartners.com/ files/QSEN%20Maine%20 11.11.ppt 46

QSEN FACULTY SELF-DIRECTED MODULES 



     

Getting Started with QSEN: Why is QSEN Important to Nursing Clinical Education Managing the Complexity of Nursing Work: Cognitive Stacking Introduction to Teaching Informatics in Clinical Courses Inter-professional education Evaluation of QSEN competencies Changing a curriculum Integrating QSEN in intermediate level courses Integrating QSEN in advanced courses 

Editor: Pam Ironside, IUPUI QSEN 47

QSEN LEARNING MODULES

Link: http://www.qsen.org/modules/

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THE

2010 IOM REPORT ON THE FUTURE OF NURSING

Key Messages: 1.

Nurses should practice to the full extent of their education and training

2.

Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression

3.

Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States

4.

Effective workforce planning and policy making require better data collection and an improved information infrastructure.

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ANALYZING STAKEHOLDER PERCEPTIONS AND SOCIAL NETWORK CONNECTIONS IMPORTANT FOR THE FUTURE OF NURSING 



RWJF engaged Dr. Fredericks and Dr. Kelly from The Sage Colleges to lead the multilevel analysis on IOM report Key Findings: Major themes about the issues include:  

 



A "clear, agreed upon" strategic plan is needed that addresses how the recommendations will be implemented The business case for implementation of some of the recommendations is not being discussed; cost savings must be demonstrated in order for those involved to be willing to work to make such changes Education leaders, especially those representing community colleges, are "critically" needed on the advisory committee Representation from the business community, including Fortune 500 companies, is needed on the advisory committee and the business community must be included in implementation efforts Despite many issues on which physician and nursing organizations can agree, scope of practice is a major roadblock to progress 50

CONDUCTING

A SOCIAL NETWORK ANALYSIS OF KEY

STAKEHOLDERS IN IMPLEMENTATION OF RECOMMENDATIONS FOR THE INITIATIVE ON THE OF 

FUTURE

NURSING

Key findings from the analysis of advisory committee members' social networks include:  Advisory committee members had the most connections with membership and advocacy organizations.  Members had a broad range of connections with the health care field  While the advisory committee members had a fair number of connections with universities and colleges (267 different institutions), almost all were with large public universities or top private institutions, with only four connections to community colleges  Less than 5 percent of total network connections were with the business sector 

Reference: http://www.rwjf.org/content/rwjf/en/research-publications/findrwjf-research/2012/09/analyzing-stakeholder-perceptions-and-socialnetwork-connections.html

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THANK YOU

QUESTIONS?

Contact Information: Mary Therriault (518) 312-6517 [email protected]

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