Strategies for Creating an Evidence-Based Practice Nursing
Culture Tanya Feddern
MLIS, AHIP, MOT, OTR/L
Kathryn EwersRN, BA, MEd
Special thanks for layout and graphics: John D Jones Jr and Sandra Benitez
May 22, 2006 MLA Annual Conference 2
Project Abstract
Title: Strategies for creating an evidence-based practice nursing culture
Author(s)/Affiliation: Tanya Feddern, AHIP, University of Miami Miller School of Medicine, Louis Calder Memorial Library, Miami, FL, Kathryn M. Ewers, Jackson Health Systems, Miami, FL.
Purpose/Setting/Participants/Resources: The purpose of our project was to develop a strategic action plan to create a nursing culture that values and utilizes evidence-based practices for the delivery of nursing care. This paper summarizes how to identify and develop educational interventions for fostering an evidence-based nursing culture at a university-affiliated public hospital in Miami, Florida. These interventions were implemented via collaboration between nurse educators and a medical librarian.
Brief Description: To evaluate nursing culture and readiness for evidence-based practice, the nurse educators utilized the PARIHS (Promoting Action on Research Implementation in Health Services) framework and adapted the RNAO’s (Registered Nurses Association of Ontario) Action Template. A descriptive survey was developed from the PARIHS framework and was used to assess cultural readiness for evidence-based practice. The RNAO template was used for identifying educational interventions. The nursing educators and medical librarian then collaborated on targeted educational interventions, such as selecting evidence-based filters for Ovid CINAHL, creating a unique evidence-based practice (EBP) certificate program consisting of collaborative continuing education classes, and brainstorming on other educational activities for the busy nurse clinician and researcher, such as an EBP online discussion list and an online journal club.
Results/Outcome: Inter- and intra-collaboration between nursing educators and the medical librarian have led to the successful creation and/or modification of educational assessments and interventions to bring about a change in nursing culture towards using EBP in clinical practice. Our survey results suggest that intensive educational strategies are resulting in a higher rate of evidence-based practice change, and that nurses’ knowledge and skills about evidence-based practice are above the national average.
May 22, 2006 MLA Annual Conference 3
Collaboration
Jackson Memorial Hospital
Louis Calder Memorial Library
May 22, 2006 MLA Annual Conference 4
Topic Overview
EBN Strategic Plan Educational Strategies
Practice Strategies
Organizational Strategies
Outcomes
Challenges
Future Plans
May 22, 2006 MLA Annual Conference 5
Framework for the Strategic Plan: EBP Culture Implementation Model
Adapted from RNAO Toolkit: Clinical Practice Guideline Implementation Model
Resources (3)Resources (3) Stakeholders (2)Stakeholders (2)
Evaluation (6)Evaluation (6)
Identify & Implement Identify & Implement EBP Model (5)EBP Model (5)
ImplementationImplementationof Strategiesof Strategies
for EBP Culture (4)for EBP Culture (4)
Assess Environmental Assess Environmental Readiness for Evidence Readiness for Evidence
Based Practice Culture (1)Based Practice Culture (1)
May 22, 2006 MLA Annual Conference 6
Educational Strategies
Developed CE classes:Intro to Evidence Based Practice
OVID MEDLINE Tutorial
OVID CINAHL Tutorial
Practice Guidelines
Included Intro EBN Class in Nursing Orientation
Developed EBN Bookmark
Developed EBN Certificate Curriculum
May 22, 2006 MLA Annual Conference 7
Timeline for EBN Curriculum
May 2004Intro class: Finding the Evidence-Introduction to EBP as CE Class (initially just to Hospital Educators)
Fall 2004OVID MEDLINE Tutorial as CE Class
January 2005Intro to EBP added to Nursing Orientation
January 2006Certificate Program in EBN Developed
January 2006UM Research Certification Class
May 22, 2006 MLA Annual Conference 8
EBN Certificate
Introduction to EBN: Finding the Evidence (required) 1.5 CEU
Either OVID MEDLINE Tutorial OR CINAHL Tutorial 2 CEU
Guidelines Class: 2 CEU (required)
EBN Project (required)
May 22, 2006 MLA Annual Conference 9
Introduction to EBP: Finding the Evidence
Led by Kathryn Ewers
Course ObjectivesGoals of EBNTypes of EvidenceIntroduced EBN modelIntroduced accessing Evidence-Based Resources
May 22, 2006 MLA Annual Conference 10
Ovid MEDLINE/CINAHL Tutorials
Led by Tanya FeddernCourse Objectives
Reinforces the EBP principles discussed in the Introduction to Evidence-Based Practice class
Introduces building a strategy for systematic searching
Shows how to get articles online, from the shelf, or via Interlibrary
Loan
May 22, 2006 MLA Annual Conference 11
Practice StrategiesDeveloped Cultural Readiness for EBP Survey
Adapted an EBN Implementation model for the Jackson Health System (JHS)
Targeted Nursing Policy and Procedure Committee for utilization of EBN model to update policies & procedures
Established Nursing Practice Councils including Standards Council and Quality Research & EBP Council
May 22, 2006 MLA Annual Conference 12
Cultural Readiness for EBP Survey
Six months after the educational interventions started, Kathryn Ewers wished to take a snapshot of EBN at the Jackson Memorial Hospital…
JUNE 2005
An online survey was developed from the Promoting Action on Research Implementation in Health Services (PARIHS) framework
1033 nurses participated during the week-long survey
Results shown on slides 13-21
May 22, 2006 MLA Annual Conference 13
Barriers to Research Utilization
11.1%Unaware of Scope of
Autonomous Nursing Practice
7%Research Not Valued
23.6%Lack of resources
16.4%Lack of skill accessing/assessing research
N=1033
41.8%Lack of Time
May 22, 2006 MLA Annual Conference 14
Resources consulted when participants had a clinical
question
Members of Healthcare Team 49%
Cochrane Collaboration 4%
Journals 13%
Policies & Procedures, Clinical Pathways/Care Plans 11%
Textbooks 11%
Internet Resources 10%
Patient 2%Clinical Practice/Best
Practice Guidelines 3.5%
May 22, 2006 MLA Annual Conference 15
Nursing Knowledge of Evidence Based Practice
%
Accessed full text, evidence-basedelectronic nursing/medical journals from the Louis Calder Memorial Library (N = 636)
Accessed a Clinical/Best Practice Guideline via internet (N = 592)
Utilized an evidence-based filter in a literature search (N = 567)
Accessed full text, evidence-based electronic nursing/medical journals from the Internet(N = 813)
30.2%
43.2%
24.9%
58.4%
69.8%
56.8%
75.1%
41.6%
Answer to “I have ….” YES NO
May 22, 2006 MLA Annual Conference 16
Nursing Knowledge of Evidence Based Practice
The 2004 ANA standards of practice require all registered nurses to: utilize evidence-based assessment techniques, evidence-based interventions and treatments specific to the patient.
The highest level of evidence in the “Pyramid of Evidence” is considered to be systematic reviews and meta-analyses.
The best way to define evidence-based/best practice is utilization of the most current and valid research combined with clinical expertise and patient preference.
60.5%
32.4%
61.8%
May 22, 2006 MLA Annual Conference 17
EBP Skill: PICO Writing
Used the “PICO” framework to form my research question
P = Patient ProblemI = InterventionC = ComparisonO = Outcome
YES
NO
87.9%12
.1%
May 22, 2006 MLA Annual Conference 18
Journal Consultation & Practice Change
Consulted journal article regarding clinical question
Changed practice due to a new research finding
0
10
20
30
40
50
60
21.2%
52.5%
15.3%21.3%
Within the last
3 months
Within theLast year More than
2 years ago
NeverWithin the last
6 months
31.7%
9.1%
15.3%
16.7%
16.8%
May 22, 2006 MLA Annual Conference 19
Cultural Context of Leadership85.1% My work place is highly task driven
77.8% The workplace culture is a learning organization that values individuals and their contribution to client care
77.6% My manager’s expectations of me are clearly defined
75.1% Life long continuous learning is highly valued by nursing leadership
68.7% Organizational nursing values & beliefs are clearly defined in my workplace
68.4% Performance evaluation relies on multiple sources and multiple methods for evaluation
63.3% On my unit, the educational philosophy is best characterized as enabling
62.9% My manager’s approach to learning, teaching and managing is empowering
61.3% Nurse leaders are visible and accessible to all levels of nursing
59.1% Organizational nursing leadership embraces change and encourages my input in the decision making
52.9% Technical nursing skills are more highly valued than critical reflection and critical thinking skills
May 22, 2006 MLA Annual Conference 20
Survey ConclusionsLarge practice gap between access of clinical practice guidelines and use of guidelines As compared to a similar survey by Pravikoff, Jackson surpasses national trends in:
Access to electronic evidence-based resourcesStrong commitment to the value of nursing researchHigher rate of practice change based on evidenceHigher rate of knowledge about EBPComprehensive, collaborative approaches to educational strategies for EBP
May 22, 2006 MLA Annual Conference 21
Survey Conclusions (continued)
Pravikoff studyThe value of research was considered the second-highest barrier to EBP
Able to define EBP 46%
Access to electronic resources 36%
Used research reports to support their practice
42%
Jackson studyThe value of research was considered a barrier to EBP
7%
Able to define EBP 61.8%
Hospital and remote access to electronic resources 100%
Used research reports to support their practice
69%
May 22, 2006 MLA Annual Conference 22
Focus for ImprovementIncrease utilization of “PICO” format for researchDevelop strategies to increase utilization of clinical practice guidelines when nurses have a clinical questionAddress nurses’ perception of lack of time as the number barrier to research utilizationEnsure adequate computer and Internet accessDevelop web page with EBP resourcesAddress leadership issues where scores are low in cultural leadership context
May 22, 2006 MLA Annual Conference 23
Nursing Model for Implementing Evidence-Based Practice Adapted from Mohide, EA and King, B. Hamilton Health Sciences (HHS) EBN Model,
which was adapted from Rosswurm ML and Larrabee JH. Image: J Nurs Sch 1999; 31:317-22.
PROPOSE/DESIGN changePROPOSE/DESIGN changein practice/policyin practice/policy
to go to relevant committeeto go to relevant committee
CONSULT best evidence resourcesCONSULT best evidence resources
DEVELOP an answerable research questionDEVELOP an answerable research question
ASSESS need for ASSESS need for change in practicechange in practice
STIMULATE inquirySTIMULATE inquiry
IMPLEMENT IMPLEMENT
SYNTHESIZE best evidenceSYNTHESIZE best evidence
EVALUATE EVALUATE
EDUCATEEDUCATE
May 22, 2006 MLA Annual Conference 24
Organizational StrategiesDovetailed Magnet & EBP activitiesMarketing - Nurse Week ActivitiesPursued International Center Membership with RNAONursing Vision and Strategic Goals include EBPNursing strategic goals aligned with Corporate Vision and goalsPartnered with academic centers Web page developmentDeveloping Unit-Based Practice CouncilsRecruited JHS nurses for Sigma Theta Tau membership
May 22, 2006 MLA Annual Conference 25
Nurse Week May 2005
May 22, 2006 MLA Annual Conference 26
Educational Outcomes 497 nurses attended Introduction to EBP class
80 nurses attended either MEDLINE/CINAHL search tutorials
EBN Certificate Graduate
JHS nurses present at International conferences on EBP
More interest in publishing
1st class of JHS nurses completes 1st course of UM School of Nursing Certificate in Research
7JHS nurses now UM CITI Certified for research with human subjects
CINAHL searches increase1,067 in 2004
14,367 in 2005
Several JHS nurses appointed as adjunct UM Nursing Faculty
May 22, 2006 MLA Annual Conference 27
Nurses’ Evaluations & Comments
OVID MEDLINE Tutorial“An excellent presenter who showed a lot of interest in her field (subject matter).”
“Tanya gave a very clear, thorough and fun tutorial. I really learned a lot about how to do a proper search. Thank you.”
Ovid CINAHL Tutorial“Normally these activities are not helpful. This one was.”
EBN Intro“Well presented. I learned a lot. Hands on helpful, wonderful speaker.”
May 22, 2006 MLA Annual Conference 28
CINAHL session searchesCumulative Index Nursing Allied Health Literature
0
2000
4000
6000
8000
10000
12000
14000
16000
2004 2005
1,067
14,367
May 22, 2006 MLA Annual Conference 29
Practice OutcomesPolicy and Procedure Committee using JHS EBP Model & EBP resources to update policies and procedures
Best Practice Guidelines used to:• Develop Falls Prevention Program• Change practice re Domestic Abuse Screening• Reduce Pressure Ulcer Prevalence in ICUs
JHS Nurses participating in reviewing Healthy Workplace Guidelines in collaboration with RNAO
Online Journal Club under development with UM Faculty & JHS nurses
May 22, 2006 MLA Annual Conference 30
Organizational OutcomesNursing Vision and Strategic Goals endorse evidence-based practice and global leadership in evidence based practiceAnticipated improvement in quality of care and patient outcomesAnticipated improvement in nurse satisfaction More respect for nurses’ knowledgeANA Magnet Standards met for EBPJHS Nursing featured in local and international nursing publicationsInterdisciplinary interaction and CEs (nurses, RTs, Pharmacists)Increased collaboration between UM & JHS
May 22, 2006 MLA Annual Conference 31
ChallengesTime constraints- compressing class contentCoordinating schedulesTime & Resources for Marketing Content modifications of CE materials from physicians to allied healthCompeting Corporate AgendasManaging contact hours and paperworkMyMedEd accessible only to JHS StaffComputer literacy variability
May 22, 2006 MLA Annual Conference 32
Future StrategiesUniversity-based listservs on EBP for Jackson Memorial Hospital (JMH) nursesOn-line/self study Course DevelopmentOn-line journal clubsJHS webpage on research and EBP for nurses Target utilization of EBN Model to Unit Based Councils for initiating practice changeProvide CEU’s for Occupational Therapy, PharmacyTie Clinical Advancement Ladder to EBP EducationJoint Conference offerings with RNAO, UM, JHSCollaborating with the UM nursing school and nurse librarian to create a continuity of EBP instruction and knowledge—from the nursing school curriculum to the hospital
May 22, 2006 MLA Annual Conference 33
Thank YouTanya Feddern
Reference & Education Services LibrarianLouis Calder Memorial Library, University of Miami Miller School of
Kathryn EwersNursing Educator Jackson Memorial Hospital in Miami,
[email protected] 305-585-7134
May 22, 2006 MLA Annual Conference 34
ReferencesCITI: Course in the Protection of Human Research Subjects
https://www.citiprogram.org/citi_information.asp
Estabrooks, C. A. (1998). Will evidence-based nursing make practice perfect? Canadian Journal of Nursing Research, 30, 15-36.
Ewers K. (2005) EBP Survey: https://www.um-jmh.org/perfimp/EBP2/EBP2.htm
Mohide, E. Ann., Coker E. (2005) Toward Clinical Scholarship: Promoting Evidence-Based Practice in the Clinical Setting. Journal of Professional Nursing, Vol 21, No 6. 372-379.
Pravikoff, D., Tanner, A., Pierce, S., (2005). Readiness of U.S. Nurses for Evidence-Based Practice. American Journal of Nursing, Vol. 105. No.9.
Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7(3), 149-158.
Registered Nurses Association of Ontario. (2005). Shaping the future of nursing: RNAO nursing best practice guidelines. Retrieved March 5, 2005 from www. rnao.org/best practices
Registered Nurses Association of Ontario (2002). Toolkit: Implementation of clinical practice guidelines. Toronto, Canada: Registered Nurses Association of Ontario.
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (Eds.). (2000). Evidence-based medicine: How to practice and teach ebm. Toronto: Churchill Livingston.
May 22, 2006 MLA Annual Conference 35
Further ReadingBrown D. McCormack B. Developing postoperative pain management: utilising the Promoting
Action on Research Implementation in Health Services (PARIHS) framework. Worldviews on Evidence-Based Nursing. 2005 3rd Quarter; 2(3): 131-41.
Donaldson NE. Rutledge DN. Ashley J. Outcomes of adoption: measuring evidence uptake by individuals and organizations. Worldviews on Evidence-Based Nursing. 2004 3rd Quarter; 1 Supplement 1: S41-51.
Ellis I. Howard P. Larson A. Robertson J. From workshop to work practice: an exploration of context and facilitation in the development of evidence-based practice. Worldviews on Evidence-Based Nursing. 2005 2nd Quarter; 2(2): 84-93.
O'Halloran P. Martin G. Connolly D. A model for developing, implementing, and evaluating a strategy to improve nursing and midwifery care. Practice Development in Health Care. 2005; 4(4): 180-91.
Rycroft-Malone J. The PARIHS framework--a framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quality. 19(4):297-304, 2004 Oct-Dec.
Wallin L. Profetto-McGrath J. Levers MJ. Implementing nursing practice guidelines: a complex undertaking... including commentary by Rycroft-Malone J. Journal of WOCN. 2005 Sep-Oct; 32(5): 294-301.
