Evidence Based Practice into Clinical Practice

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Chapter 9

Implementing Evidence in Clinical Settings

Essential Elements Needed to Create an EBP Environment

(With permission from Hockenberry, M., Walden, M., Brown, T., & Barrera, P. (2007). Creating an evidence-based environment: One hospital’s journey. Journal of Nursing Care Quality, 22(3), 223.)

Why Create an EBP Clinical Environment?

Regulatory initiatives and insurance-mandated outcomes
National Strategy for Quality Improvement in Healthcare’s “triple aim”
Magnet Recognition Program’s expectations that the nursing culture promotes superior performance through EBP

Essential Objectives for an EBP Vision

Objectives

Develop a mental framework

Establish a motivating image for change

Create specific goals

Gain administrative support

Establish a leadership team

Involve experts and EBP mentors in clinical practice

Strategies for an EBP Vision

Objectives	Strategies
Develop a mental framework	Develop a written summary of what you want to accomplish Brainstorm with colleagues regarding the environment you want to create
Establish a motivating image for change	Use creativity to capture attention of the clinical staff Take advantage of real clinical scenarios to stress the need for changes in practice
Create specific goals	Focus on short-term, attainable goals Establish only two or three goals at a time

Strategies for an EBP Vision—(cont.)

Objectives	Strategies
Gain administrative support	Create a presentation that reflects the need for transforming the culture into an EBP environment Seek administration support for the project to be identified as an organizational priority
Establish a leadership team	Identify key personnel with a passion for EBP Conduct small focus group meetings
Involve experts and mentors in clinical practice	Identify clinical experts and EBP mentors Engage clinical expert support

Question

Is the following statement true or false?

Implementation of EBP is the responsibility of graduate-prepared nurses and members of the nursing leadership.

Answer

False

Rationale: Implementation of EBP in the clinical setting is dependent on broad engagement and participation from all care providers at all levels, as well as leaders, administrators, and members of other disciplines.

Common Barriers to Implementing Evidence-Based Practice

Barriers	Rationale
Inadequate knowledge and skills	The best evidence-based policies are of no value when staff lack knowledge of how to implement them in practice
Weak beliefs about the value of EBP	Poor dissemination of the relationship between evidence-based practice and patient outcomes can result in weaker belief in the effectiveness and efficacy of EBP
Poor attitudes toward EBP	Negative attitudes about clinical research can make it difficult for staff to become engaged in EBP

Common Barriers to Implementing Evidence-Based Practice—(cont.)

Barriers	Rationale
Lack of EBP mentors	Findings from research have indicated that a lack of EBP mentors in the environment also can be a barrier to implementing EBP by point-of-care staff
Lack of support by leaders and clinicians	Knowledge, attitudes, and beliefs of mid-level and upper-level administrators and their perceived roles in communicating support for this change affect lower-level support

Common Barriers to Implementing Evidence-Based Practice—(cont.)

Barriers	Rationale
Economic restrictions	Lack of consideration that one type of cost may be readily offset with savings in time (i.e., workload), satisfaction, or the additional expense of patient complications

Objectives and Related Strategies to Develop Staff Engagement in EBP

Objective	Strategies
Engage staff and stakeholders in assessing and eliminating barriers	Engage stakeholders to identify educational content and strategies to learn about the practice change Seek information from staff about their attitudes toward the affected practice Involve influential staff and leaders in conducting discussions with colleagues

Objectives and Related Strategies to Develop Staff Engagement in EBP—(cont.)

Objective	Strategies
Prioritize clinical issues	Select clinical issues of direct interest and responsibility of clinician stakeholders Choose issues with solid empiric evidence to begin an organizational area’s EBP endeavors

Objectives and Related Strategies to Develop Staff Engagement in EBP—(cont.)

Objective	Strategies
Evaluate the infrastructure	Determine the individuals and committees who have decision-making authority Gain administrative support for adequate time and personnel for the initiative Enlist experts to lead EBP initiatives Ensure access to databases, search engines, and full-text articles

Objectives and Related Strategies to Develop Staff Engagement in EBP—(cont.)

Objective	Strategies
Develop experts in the evidence-based process	Utilize leaders within the organization or form an academic partnership to provide expertise in research, EBP design, and evaluation Provide formal classes and/or small-group sessions on finding and evaluating evidence Mentor staff in critically appraising research studies and formulating practice recommendations

Question

Which of these strategies below is the most effective strategy for engaging care providers in a proposed EBP change?

Disseminating the evidence that underlies the proposed change
Reminding staff of their obligation to provide optimal care
Bringing in EBP experts to speak to staff members
Creating dissatisfaction with current practice and outcomes

Answer

d. Creating dissatisfaction with current practice and outcomes

Rationale: If care providers are not satisfied with the status quo, then they will be open to evidence-based change. Other strategies, such as bringing in outsiders to teach, disseminating research findings, and telling caregivers that they are obliged to change, are less likely to engage them and foster genuine change.

Integration of EBP into the Clinical Environment

Objective	Strategies
Establish formal implementation teams	Enlist APNs and other expert staff as clinical team leaders
Build excitement	Create discomfort with the status quo Enlist local opinion leaders who can attest to the need for practice change Bring in outside speakers who have the potential to connect and inspire key stakeholders

Integration of EBP into the Clinical Environment—(cont.)

Objective	Strategies
Disseminate evidence	Utilize multifaceted strategies to overcome knowledge deficits, skill deficits, and skepticism Promote experience sharing to emphasize the need for change and positive outcomes of change Provide time to assimilate new practices

Integration of EBP into the Clinical Environment—(cont.)

Objective	Strategies
Develop clinical tools	Anticipate tools and processes that the staff will need to transform practice Revise patient care documentation records Ensure easy access to clinical resources Integrate alerts and reminders into workflow processes at the point of care Repeatedly expose the staff to evidence-based information

Integration of EBP into the Clinical Environment—(cont.)

Objective	Strategies
Pilot test	Choose pilot sites with consideration to unit leadership strength, patient population diversity, acuity, and geographic location Address the root causes of problems Decide to adopt, adapt, or abandon at the end of the pilot test
Preserve energy sources	Engage support personnel Implement smaller, more manageable projects Anticipate setbacks and have patience and persistence

Integration of EBP into the Clinical Environment—(cont.)

Objective	Strategies
Allow enough time	Develop incremental project steps Establish a timeline
Celebrate success	Acknowledge the staff instrumental in process Ensure recognition by supervisors and administration

Evaluating Outcomes of EBP Change

Area of Evaluation	Examples
Outcomes	Measures of death, disability, iatrogenic effects of treatment, health behaviors, economic impact of therapy, and illness management
Quality care improvement	Success of symptom management such as pain, fatigue, nausea and vomiting, sleep disturbance, and depression
Patient-centered quality care	Patient perception of healthcare providers’ effective communication, consideration of cultural and religious beliefs, respect, empathy, and caring attitude

Evaluating Outcomes of EBP Change— (cont.)

Area of Evaluation	Examples
Efficiency of processes	Timeliness of procedures, medication administration, diagnostic tests, transfer, and discharge
Environmental changes	Unit/department resource (equipment, supplies, and personnel) availability
Professional expertise	Knowledge and competency of staff

Question

When considering the six areas of EBP evaluation of the clinical environment, which of the following is considered an outcome measure?

Number of times that heart failure patients are discharged within the case management time parameter
Incidence of pressure ulcers
Number of discharged patients who are satisfied with their pain management
Average turnaround time needed for repair of inoperative intravenous pumps

Answer

c. Incidence of pressure ulcers

Rationale: Incidence of pressure ulcers is an iatrogenic effect of hospitalization. The number of times that heart failure patients are discharged within the case management time parameter is an example of the efficiency of processes. The number of discharged patients who are satisfied with their pain management is an example of patient-centered quality. The average turnaround time needed for repair of inoperative intravenous pumps is a measure of the availability of resources.