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Original Article

A Test of the ARCC C© Model Improves Implementation of Evidence-Based Practice, Healthcare Culture, and Patient Outcomes Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FAANP, FNAP, FAAN • Ellen Fineout-Overholt, RN, PhD, FNAP, FAAN • Martha Giggleman, RN, DNP, NEA-BC • Katie Choy, RN, DNP, CNS, NEA-BC

Keywords

ARCC, evidence-based

practice, organizational

culture, patient outcomes

ABSTRACT Background: Although several models of evidence-based practice (EBP) exist, there is a paucity of studies that have been conducted to evaluate their implementation in healthcare settings.

Aim: The purpose of this study was to examine the impact of the Advancing Research and Clinical practice through close Collaboration (ARCC) Model on organizational culture, clinicians’ EBP beliefs and EBP implementation, and patient outcomes at one healthcare system in the western United States.

Design: A pre-test, post-test longitudinal pre-experimental study was conducted with follow-up immediately following full implementation of the ARCC Model.

Setting and Sample: The study was conducted at a 341-bed acute care hospital in the western region of the United States. The sample consisted of 58 interprofessional healthcare professionals.

Methods: The ARCC Model was implemented in a sequential format over 12 months with the key strategy of preparing a critical mass of EBP mentors for the healthcare system. Healthcare professionals’ EBP beliefs, EBP implementation, and organizational culture were measured with valid and reliable instruments. Patient outcomes were collected in aggregate from the hospital’s medical records.

Results: Findings indicated significant increases in clinicians’ EBP beliefs and EBP implementation along with positive movement toward an organizational EBP culture. Study findings also indicated substantial improvements in several patient outcomes.

Linking Evidence to Action: Implementation of the ARCC Model in healthcare systems can en- hance clinicians’ beliefs and implementation of evidence-based care, improve patient outcomes, and move organizational culture toward EBP.

INTRODUCTION AND BACKGROUND It is well known that evidence-based practice (EBP) improves healthcare quality, safety, and patient outcomes as well as fos- ters clinicians’ active engagement in their practices. Nurses who use an evidence-based approach to care and practice in cultures that support EBP are more empowered as they are able to make a difference in the care of their patients. Although the positive impact of EBP has been demonstrated through multiple studies, major barriers exist that prevent EBP from becoming the standard of care throughout the world. These barriers include (a) inadequate EBP knowledge and skills of clinicians, (b) misperceptions that EBP takes too much time, (c) organizational culture and politics, (d) lack of support from nurse leaders and managers, and (e) inadequate resources and investment in EBP (Jun, Kovner, & Stimpfel, 2016; Melnyk et al., 2016; Melnyk, Fineout-Overholt, Gallagher-Ford, & Ka-

plan, 2012). Aside from equipping clinicians with the knowl- edge and skills needed to attain the EBP competencies and con- sistently implement evidence-based care, findings from studies have indicated that clinician access to EBP mentors can play a key role in their implementation of EBP and the development of organizational cultures that support the delivery of evidence- based care (Fineout-Overholt & Melnyk, 2015; Melnyk, 2007).

Although several EBP models exist, most are process mod- els that outline the steps of EBP or the sequence of conducting an EBP project. EBP process models include the Johns Hopkins Nursing Evidence-Based Practice Model (Dearholt & Dang, 2012), the Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001), the Model for Evidence-Based Practice Change (Rosswurm & Larabee, 1999), and the ACE Star Model of Knowledge Transformation (Stevens, 2012). Unlike EBP process models, the Advancing Research and

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A Test of the ARCC C© Model Improves Implementation of Evidence-Based Practice

Figure 1. The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model.

Clinical practice through close Collaboration (ARCC) Model is a system-wide model to advance and sustain EBP in healthcare systems (see Figure 1). The first step in implementing the ARCC Model is an organizational assessment of the current EBP culture in order to identify strengths and major barriers to EBP in the healthcare system so that strategies can be implemented to remove those barriers. At the core of the ARCC Model is a critical mass of EBP mentors who, through intentional strategic initiatives, assist point of care clinicians in enhancing their beliefs about the value of EBP and their confidence in implementing it. As a result, ARCC contends that heightened EBP beliefs in clinicians result in greater implementation of evidence-based care, which ultimately leads to higher job satisfaction, less staff turnover, and improved patient outcomes. Several studies now support the relationships among key constructs in the ARCC Model (Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011; Melnyk, 2012; Melnyk & Fineout-Overholt, 2002; Melnyk et al., 2004; Melnyk, Fineout-Overholt, & Mays, 2008; Melnyk, Fineout- Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010).

AIM The purpose of this study was to examine the impact of the ARCC Model on organizational culture, clinicians’ EBP beliefs and EBP implementation, and patient outcomes at one health- care system in the western region of the United States.

DESIGN A pre-test, post-test longitudinal pre-experimental study was conducted with follow-up immediately following full imple- mentation of the ARCC Model. Institutional Review Board ap- proval was obtained from the authors’ institution as well as the organization’s research subject review board.

SETTING AND SAMPLE This study was conducted at Washington Hospital Healthcare System, a 341-bed acute care hospital in the San Francisco bay area. The sample consisted of 58 interprofessional health- care professionals, with complete follow-up data for 45 partic- ipants. Participants were point of care nurses, administrators, nurse managers, clinical nurse specialists, respiratory thera- pists, occupational therapists, physical therapists, dieticians, social workers, and pharmacists. Although physician cham- pions participated in the projects, they were not part of the data collection. Only the project teams participated in data collection.

METHODS The ARCC Model was implemented in a sequential format over 12 months with the key strategy of preparing a critical mass of EBP mentors for the healthcare system. Intensive EBP workshops were first provided to the 58 participants in order to enhance their knowledge and skills in the seven steps of

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Original Article Table 1. Examples of PICOT Questions Formulated by the EBP Teams

� In ventilated intensive care unit patients (P), how does early ambulation (I) compared to routinely scheduled ambulation (C) affect length of stay and episodes of ventilator associated pneumonia while in the intensive care unit (T)

� In congestive heart failure patients (P), how does comprehensive pre-discharge education (I) compared to standard pre-discharge education (C), affect readmission rates to the hospital (O)?

EBP. In addition, content and skills building in the workshops focused on how to facilitate individual behavior change of clin- icians to implement EBP and how to facilitate an EBP organi- zational culture. The 58 participants were divided into working teams of six to eight members who were to collaborate on an EBP change project to improve patient outcomes within the hospital. Each team was then charged with formulating a PICOT (Patient population, Intervention or Issue of inter- est, Comparison intervention or issue, Outcome, and Time for the intervention to achieve the outcome if relevant) question about an important clinical issue, systematically searching for the best evidence, and critically appraising and synthesizing the evidence culminating in a recommendation for practice. See Table 1 for examples of PICOT questions developed by the teams. Strategic plans were then developed by the inter- professional EBP mentor teams to implement and evaluate the impact of the EBP changes on clinical outcomes within their organization. After implementation and evaluation of the prac- tice changes were completed, the final step for the teams was to submit their projects for presentation at local, regional, or national conferences to disseminate their successes to others within the healthcare community.

OUTCOMES Study variables were measured with the following valid and reli- able instruments. The Evidence-Based Practice Beliefs (EBPB) Scale Melnyk & Fineout-Overholt, 2003a) measured clinicians’ beliefs about EBP and their ability to implement it. The 16-item Likert scale has established face, content, and construct valid- ity with internal consistency reliabilities greater than .85 across multiple studies (Melnyk et al., 2008). Responses on the scale range from 1 (strongly disagree) to 5 (strongly agree). Examples of items on the scale include (a) I am clear about the steps in EBP, (b) I am sure that I can implement EBP, and (c) I am sure that evidence-based guidelines can improve care.

The Evidence-Based Practice Implementation (EBPI) Scale measured delivery of evidence-based care (Melnyk & Fineout- Overholt, 2003b). Participants respond to each of the 18 Likert scale items on the EBPI by answering how often in the last eight weeks they have performed certain EBP activities, such as (a) generated a PICOT question about my practice, (b) used evi-

dence to change my clinical practice, (c) evaluated the outcomes of a practice change, and (d) shared the outcome data collected with colleagues. The EBPI has established face, content, and construct validity as well as internal consistency reliabilities greater than .85 across multiple studies (Melnyk et al., 2008).

The Organizational Culture and Readiness Scale for System-Wide Integration of Evidence-Based Practice (OCR- SIEP) measured the organization’s culture and its readiness for system-wide EBP (Fineout-Overholt & Melnyk, 2006). This instrument contains 26 Likert scale items that identify a de- scription of the existing support in the current culture for EBP, which offers insight into the strengths and opportunities for fostering evidence-based care within a healthcare system. The OCRSIEP scale has established face and content validity along with excellent internal consistency reliability of greater than .85 across multiple samples (Melnyk & Fineout-Overholt, 2015). Examples of items on the OCRSIEP include the following: (a) To what extent is EBP clearly described as central to the mission and philosophy of your institution? (b) To what extent do you believe that EBP is practiced in your organization? And (c) To what extent is the nursing staff with whom you work committed to EBP?

Patient Outcomes Aggregate data were gathered by the teams, including data from the hospital’s medical records (e.g., number of cases of ventilator associated pneumonia, hospital readmission rates) before and after implementation of the ARCC Model to evaluate relevant patient outcomes as results of the EBP projects.

Analyses T tests and effect sizes were calculated for study variables to evaluate pre-to-post differences. A p value of .05 was set for statistical significance.

RESULTS Findings indicated that the clinicians’ EBP beliefs, EBP im- plementation, and movement of organizational culture toward EBP significantly increased over the 12-month project. Specif- ically, clinicians’ EBP beliefs (n = 45) increased significantly from baseline (M = 60.7, SD = 7.6) to follow-up (M = 64.9, SD = 6.7; t = 4.2; p = .00; effect size = .62, which is a medium to large positive effect for ARCC). EBP implementation also significantly increased from baseline (M = 17.8, SD = 10.3) to follow-up (M = 51.9, SD = 16.8; t = 12.9; p = .00; effect size = 2.3, indicating a large positive effect for ARCC). In addition, organizational culture and readiness for EBP increased signifi- cantly from baseline (M = 80.9; SD = 90.8) to follow-up (M = 90.8; SD = 14.7; t = 3.9; p = .00; effect size = .70, which is a medium to large positive effect for ARCC). In addition, as a result of implementing the ARCC Model, evidence-based interventions improved key patient outcomes (see Table 2).

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A Test of the ARCC C© Model Improves Implementation of Evidence-Based Practice

Table 2. Project Outcomes From Implementation of the EBP Changes

� A practice change to early ambulation in the ICU led to a 2.7 reduction in ventilator days (11.6–8.9) and no ventilator associated pneumonia.

� With the implementation of a pressure ulcer prevention nursing standardized procedure on a medical-surgical unit, the acquired pressure ulcer rate was significantly decreased from 6.07% to 0.62% 1 year later.

� Comprehensive education of congestive heart failure patients led to a 14.7% reduction in hospital readmissions.

� After implementation of family centered care on the pediatric unit, 75% of parents perceived the overall quality of care as excellent compared to 22% pre-implementation.

� The percentage of mothers not supplementing their breast milk with formula increased from 61.7% to 71.1% after the evidence-based baby friendly hospital initiative was implemented.

� After implementation of a nurse-initiated pain protocol in the emergency room (ER), wait time for pain medication decreased from 46 minutes to 13 minutes and length of stay in the ER also decreased from 120 minutes to 91 minutes.

DISCUSSION Findings support the positive impact of implementing the ARCC Model on clinicians’ EBP beliefs and a dramatic in- crease in EBP implementation in those who participated in the project. Organizational culture at the hospital shifted greatly toward system-wide EBP. Most important, as a result of imple- menting ARCC, there were multiple improvements in patient outcomes.

The establishment of a cadre of EBP mentors is cen- tral to building an organizational culture of EBP and im- plementing evidence-based care. The EBP mentors in this study garnered the knowledge and skills needed to successfully implement and evaluate EBP changes within the hospital as well as to work with their colleagues in creating an EBP culture in which to deliver high-quality evidence-based care. These findings affirm that culture eats strategy and assists clini- cians in making EBP the social norm within a system (Mel- nyk, 2016b). Without a culture and environment that supports EBP, high-quality evidence-based care will not sustain (Melnyk, 2016a).

Numerous healthcare systems and hospitals throughout the United States and globe have implemented the ARCC Model in their efforts to build and sustain an EBP culture and environ- ment in their organizations. As a part of building this culture, position descriptions have been created or changed to include responsibilities as an EBP mentor. For example, at The Ohio State University Wexner Medical Center, the primary responsi- bility of the clinical nurse specialists throughout the healthcare system is to serve as EBP mentors for point of care staff in improving patient outcomes. Part of this role is ensuring

compliance with the EBP competencies for advanced practice nurses (Melnyk, Gallagher-Ford, & Fineout-Overholt, 2016; Melnyk, Gallagher-Ford, Long & Fineout-Overholt, 2015).

Research is needed to further confirm the advantages of using particular EBP models in real-world practice settings, including how implementation of these models impact both clinician, leader and patient outcomes (Dang et al., 2015). Com- parative effectiveness studies that evaluate the benefits of in- dividual models as well as combining models also are needed. Those hospitals and systems who use an EBP model to guide implementation of evidence-based care should document their experiences and outcomes in order to better understand the model’s usefulness in facilitating EBP and share this impor- tant information with others who might use the model (Gra- ham, Tetroe, & KT Theories Research Group, 2007). Return on investment by including cost outcomes also should be eval- uated. WVN

LINKING EVIDENCE TO ACTION

� The ARCC Model is an evidence-based system- wide model for advancing the implementation and sustainability of EBP.

� A key strategy in the ARCC model is the develop- ment of a critical mass of EBP mentors who assist point of care clinicians in the consistent imple- mentation of evidence-based care.

� Use of ARCC EBP mentors enhances the EBP be- liefs and EBP implementation of clinicians and strengthens the EBP culture of an organization.

� An organizational culture of EBP is central to sup- porting sustainable high quality evidence-based care.

� Implementation of the ARCC Model can substan- tially improve patient outcomes.

Author information

Bernadette Mazurek Melnyk, Associate Vice President for Health Promotion, University Chief Wellness Officer, Dean and Professor, College of Nursing, Professor of Pediatrics & Psychiatry, and College of Medicine, The Ohio State Univer- sity, Columbus, Ohio; Ellen Fineout-Overholt, Mary Coulter Dowdy Distinguished Professor of Nursing, College of Nurs- ing & Health Sciences University of Texas at Tyler, Tyler, Texas; Martha Giggleman, Healthcare Consultant & Advocate Liver- more, California; Katie Choy, Senior Director, Nursing Practice and Education, Washington Hospital Healthcare System, Fre- mont, California

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Original Article Address correspondence to Dr. Bernadette Mazurek Melnyk,

The Ohio State University, 145 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210; Melnyk.15@osu.edu

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