S

2014  Doctors  of  Nursing  Practice  Seventh  National  

Conference  The  DNP  in  Practice:  The  

Health,  the  Care,  and  the  Cost    October  8,  9  &  10,  2014  

Nashville,  TN  

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Assessment  of  Barriers  to  Research  and  Evidence  Based  Practice  in  Nursing  Practice:  

The  Results  of  Two  Independent  Studies  

 Dr.  Sandra  Copeland  &  Dr.  Laurie  Parkman  

Purpose  

To  s%mulate  discussion  and  innova%ve  project    

ideas  that  reduce  barriers  to  research/EBP    

u%liza%on  by  nurses,  fostering  quality,  cost    

effec%ve  pa%ent  care  that  reforms  healthcare.  

Operational  DeAinitions  

S  Evidence-­‐based  prac/ce:  integra%on  of  a  provider’s  clinical  exper%se,  pa%ent  characteris%cs  and  seEng,  and  best  available  proven  interven%ons  to  provide  care.  

 (Straus,  Glasziou,  Richardson,  &  Haynes,  2011)  

S  Research  u/liza/on:  a  process  of  using  findings  from  conduc%ng  research  to  guide  prac%ce  or  the  process  by  which  scien%fically  produced  knowledge  is  transferred  to  prac%ce.  

 (Barnsteiner  &  Prevost,  2002)  

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Overview  of  Barriers  to  EBP  and  Research  

Utilization  

Because  of  the  varying  educa%on  levels  of  clinicians,  levels  of  exposure  to  research,  understanding,  and  commitment  to  research  ac%vi%es  vary  by  care  seEngs,  it  becomes  the  key  role  of  the  CNO  to  make  these  assessments  and  determine  the  strategies  needed  to  be  implemented  within  the  organiza%on    (Drenkard,  2013).    

Literature  

S The  majority  of  nurses  rely  on  colleagues  or  pa%ents  as  references  (Thomson,  2003).  

S Most  nurses  prac%ce  based  on  what  they  learned  in  nursing  school  (Pravikoff  et  al.,  2005).    

S Transla%on  of  research  findings  into  prac%ce  averages  17  years  or  more  

 (Bemmel  J,  2000).  

Literature  

S Ongoing issues pose significant barriers to generate and translate knowledge to improved patient care.

S  Institute of Medicine’s 2020 goal that 90% of clinical decisions be evidence-based.

(The IOM’s Roundtable on Evidence-Based Medicine, 2007)

Literature  

S Although  evidence-­‐based  healthcare  results  in  improved  pa%ent  outcomes  and  reduced  costs,  nurses  do  not  consistently  implement  them  and    barriers  remain  prevalent.  

S Differences  existed  in  responses  of  nurses  from  Magnet®  versus  non-­‐Magnet  ins%tu%ons  (Melnyk  et  al.,  2012).  

Barriers  IdentiAied  in  Literature  (Funk  et  al.,  1995;  Squires  et  al.,  2011)  

S Characteris%cs  of  the  organiza%on.  

S  Lack  of  authority  to  change  pa%ent  care.  

S  Lack  of  %me  to  read  research.  

Barriers  IdentiAied  in  Literature  (Funk  et  al.,  1995;  Squires  et  al.,  2011)

S  Lack  of  awareness  of  related  research.  

S  Complexity  of  research  reports.  

S  Insufficient  %me  to  conduct  research.  

S  Lack  of  value  for  research  in  prac%ce.  

S Lack of administrative support

 

Barriers  IdentiAied  in  Literature  (Funk  et  al.,  1995;  Squires  et  al.,  2011)

S  Feeling  overwhelmed  by  the  process.  

S  Lack  of  knowledgeable  mentors.  

S  Lack  of  educa%on  about  the  research  process.  

S  Lack  of  administra%ve  support.    

 

Who  cares?  

S  The  assessment  of  aEtudes  and  barriers  that  impact  research/EBP  u%liza%on  in  prac%ce  is  an  essen%al  part  of  impac%ng  pa%ent  and  popula%on  quality  care,  cost,  and  sa%sfac%on  with  the  healthcare  experience.  

Outcomes  Impact  

S  Common  pa%ent  outcomes  improved  through  the  use  of  EBP  checklists  include  decreased  blood  transfusion  reac%ons,  decreased  incidence  of  wrong  pa%ent  or  wrong  limb  opera%ons,  decreased  incidence  of  ven%lator-­‐associated  pneumonia,  and  decreased  rates  of  infec%on.  

   (Pronovost,  Needham,  Berenholzt,  2006)  

S  Leads  to  decreased  LOS  and  decreased  costs  of  care.  

 

Tools  Variables   Instruments   Measurements   Ra/onale  for  Fit  

Barriers to research utilization for direct care registered nurses in Magnet® facility  

BARRIERS to Research Utilization Scale

Subscales: adopter characteristics (Cronbach alpha 0.80)

organizational characteristics

(Cronbach alpha 0.80)

innovation of the research

(Cronbach alpha 0.72)

communication of the research

(Cronbach alpha 0.65)    

29 Likert Scale Range 1-4 “ To a Great Extent to No Extent” the item is a barrier. Lower scores representing the item is not a barrier and higher scores representing an item is a barrier to a great extent.  

Tool based on DOI theory, used consistently in literature to identify barriers to research in practice, yielded consistent results  

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Dr.  Sandra  Copeland  

Project  1:  Barriers  to  U/liza/on  of  

Nursing  Research  in  a  Magnet®  Designated  Hospital  

Sample    

Sample Population Meeting Inclusion Criteria n=206  __________________________________________________________  

N %      

Male   25   12.1      

Female   181   87.9      

Full time   185   89.8      

Part time   16   7.8      Contract/flex   5   2.4      Education level      

Diploma   4   1.9      Associate degree   53   25.7      Bachelor's degree   122   59.2      Masters   27   13.1      

   

Nursing as first career   146   70.9      Service line      

Adult ICU   6   2.9      Cardiology   55   26.7      Medical/surgical   65   31.6      Emergency   21   10.2      OR/Procedural   33   16      Pediatrics   16   7.8      

   

National Certification   72   35      

 

Sample  

S  Mean  age:  

   40.38  years  (SD  11.372)  

 

S  Mean  years  of  experience:    

 14.53    years  (SD  10.44)  

S  Mean  %me  since  last  research  course:    

   4.43  years  (SD  7.231)  

 

New  or  Unusual  Demographic  Barriers    

 

S  Time  since  last  research  course.  

S  ACLS/PALS  versus  Cer%fica%on.  

S  Service  Lines/Pockets  (not  new  but  rare).  

S  Nursing  as  a  first  career.  

S  Administra%ve  turnover,  change  in  pa%ent  care  delivery  and  staffing  models.  

“The  Amount  of  Research  Information  is  Overwhelming”  

The  un-­‐scored  question  had  a  mean  score  of  2.73(  SD  .881)      

 

S  PALS/ACLS      2.1849          Full  %me    2.7486    

S  RNC        2.4417    Bachelors  2.7542  

S  Part  %me    2.5000    APRN    2.7778  

S  Not  first  career        2.5385    Med/surg    2.7937  

S  Cardiology      2.5490    First  career  2.8014  

S  Masters          2.6538    Diploma    3.000  

S  Emergency        2.6667    Adult  ICU    3.000  

S  Associate  degree          2.6875  

S  OR/Procedural        2.70  

S  Peds      2.7151  

Among  CertiAied  Nurses  

S Mean  scores:  

 Advanced  Prac%ce  Registered  Nurses  

       (n=9)  2.6413      

 Registered  Nurse  Cer%fied  

       (n=41)  2.4417      

Guess  What  Year?  

The  purpose  of  this  study  was  to  present  findings  about  the  costs  and  benefits  derived  from  a  collabora%ve  approach  in  teaching  undergraduate  nursing  research.  Data  were  collected  from  students  who  completed  38  collabora%ve  research  projects.    

The  greatest  costs  were  related  to  %me  for  mee%ng  and  maintaining  involvement.  The  greatest  benefits  reported  were  enhancement  of  intellectual  s%mula%on  and  support  received  from  student  peers.  

 A  number  of  significant  differences  for  costs,  benefits,  sa%sfac%on,  and  marks  were  found  related  to  student  group  size  and  type  of  project.  The  degree  to  which  the  benefits  of  collabora%on  were  subscribed  to  by  students  reflect  in  part  the  value  students  perceived  in  working  together  and  the  advantages  of  collabora%on  in  learning  nursing  research.    

The  chief  advantages  were  promo%on  of  a  context  for  research  which  was  congruent  with  the  reali%es  of  nursing  prac%ce,  the  complexity  and  difficulty  of  clinically  oriented  research,  and  the  knowledge  that  nursing  research  ojen  requires  coopera%on  if  findings  are  to  be  meaningful  and  possess  implica%ons  that  can  be  translated  into  prac%ce.  

Pennebaker,  D.F.  (XXXX).  Teaching  nursing  research  through  collabora%on:  costs  and  benefits.  J  Nurs  Educ,  30  (3),  pgs  102-­‐108.  

Cost/BeneAit  Project  1  

S  EBP  fellowship  grants  

S  Streamlining  educa%on  &  research  ini%a%ves  

S  Reten%on  

S  EBP  projects  

S  Nurse  Surveys  

S  Merging  of  faculty/hospital  posi%ons  

S  Magnet  cost  versus  benefit  

Turnover  Cost  

S  Studer  Group’s  data  suggest  every  1%  reduc%on  in  turnover  saves  direct  costs  of  $250,000  and  $500,000  in  indirect  costs.  

 

Betbeze,  P.  (2010).  Lower  mortality,  higher  pa%ent  sa%sfac%on  starts  with  turnover.  HealthLeaders  Media.  Retrieved  from  hnp://www.healthleadersmedia.com/content/LED-­‐  253573/Lower-­‐Mortality-­‐Higher-­‐Pa%ent-­‐Sa%sfac%on-­‐Startswith-­‐Turnover.html    

How  Much  Does  it  Cost  to  Survey  Nurses?  

S  NDNQI  

S  Towers-­‐Watson  Engagement  

S  SurveyMonkey®  or  other  

S  Others  

S   In-­‐house  

Magnet  Costs    

Some  of  the  costs  involved  in  achieving  Magnet  status  include  fees  from  the  ANCC  based  on:  

S   number  of  beds,    

S  American  Nurses  Associa%ons  Na%onal  Database  of  Nursing  Quality  Indicators®(NDNQI)  costs  related  to  the  site  visit,  

S  internal  replacement  costs  for  RN  staff  anending  mee%ngs,  

S  salaries  for  a  director  and  possible  project  manager  to  drive  the  project,  salary  for  the  hire  of  a  director  of  research,    

S  salaries  for  any  consultant  fees  (iden%fy  gap  analysis,  wri%ng,  etc.),    

S  any  costs  for  use  of  editors  when  wri%ng  the  submission.    

For  these  par%cular  organiza%ons  the  annual  costs  ranged  from  $100,000  to  a  maximum  of  $600,000  for  1  year  of  this  journey,  with  varying  ranges  in  between  years.  

Russell,  J.  (2010).  Journey  to  Magnet™:  Cost  vs.  Benefits.    NURSING  ECONOMIC$.  Vol.  28/No.5    

Cost  of  EBP  and  Research  

?  

Impact  from  External  Sources  

S  Economy  downturn  (funding,  re%rement)  

S  ACA  

S  VA  

S  Immigra%on  

S  Price  of  fuel  

S  Unemployment  rates  

S  Minimum  wage  

S  Changing  regula%ons  and  agencies    

MD  Anderson  

APRN  Implications  

S  Educa%on  of  APRNs  

S  Didac%c,  Lab  or  combina%on  research  course  

S  Technology  (esurvey,  compara%ve  database)  

S  Reten%on  (how  ojen  inservices)  

S  Liability/Standard  of  Care  

S  Results  atypical:  Masters  prepared  perceived  higher  barriers  to  research  u%liza%on  

S  Barriers:  “not  available,  sta%s%cal  analysis,  unaware,  no  %me  to  read,  overwhelming”  

Implications  for  Future  Studies  

S  Retainment  of  Research  Educa%on    

 (Collegiate  and  facility)  

S  Frequency  and  content  of  informa%on  

S  Hybrid:  didac%c:  clinical  inquiry  

S  Work  environment(culture,  pa%ent  acuity)  

S  Amount  of  CE  paid,  completed  

S  APRN roles individually (CNM, NP, CRNA, CNS)

S  Supervision, collaborative, autonomous, etc.

S  Initial education preparation: grandfather clause

S  Tool, correlation, or qualitative: measuring “under” utilization vs. outcomes

S  Impact from external issues (economic, social, political, etc.)

 

S

   

Project  2:  Assessing  CertiAied  Registered  Nurse  

Anesthetists’    Attitudes  Toward  and  Barriers  to  the  Use  of    

Evidence-­‐Based  Anesthesia  Practice  

 Dr.  Laurie  Parkman  

 

Assessing Certified Registered Nurse Anesthetists’ Attitudes Toward and Barriers to

the Use of Evidence-Based Anesthesia Practice

   S  The  purpose  of  this  project  was  to  examine  aEtudes  

regarding  perceived  barriers  and  facilitators  of  the  use  of  evidence-­‐based  prac%ce  in  CRNAs    

S  Iden%fica%on  of  barriers  to  incorpora%ng  EBP  into  CRNAs’  prac%ce  is  necessary  before  interven%ons  to  reduce  barriers  can  be  implemented  

Variables  Studied  

CRNAs’    

S  age    

S  gender    

S  ethnicity    

S  level  of  educa%on    

S  number  of  years  as  a  CRNA  

Variables  Studied  

S  prac%ce  environments  

S  type  of  primary  job  facility  

S  medical  supervision  

S  independent  contractor  

S  urban  or  rural  loca%on  

S  ease  of  access  to  Internet  for  research  

 

Study  Overview  

S  Quan%ta%ve  S  962  emails  sent  via  AANA  to  CRNAs  in  GA  S  92  respondents  

S  Qualita%ve  S  14  personal  interviews  

Clinical  Questions  

S  Clinical  Ques/on:    What  are  CRNAs’  common  perceived  barriers  that  discourage  implementa%on  of  EBP?  

S  Clinical  Ques/on:  What  are  CRNAs’  common  perceived  facilitators  that  encourage  implementa%on  of  EBP?  

Clinical  Questions  

S  Clinical  Ques/on:  Is  there  a  rela%onship  between  perceived  barriers  to  the  implementa%on  of  EBP  and  demographic  variables  (CRNAs’  age,  gender,  ethnicity,  level  of  educa%on,  number  of  years  as  a  CRNA)?  

Sample  

S  ages  ranged  from  25  -­‐  74  years  

S  35-­‐44  and  55-­‐64  (28.3%)    

S  65-­‐74  (5%)  

S  female  (55.4%)  

S  white  (69.6%)    

S  Masters  degree  (75%)  

S  years  experience  16.4  (11.8)  

Clinical  Question:    What  are  CRNAs’  common  perceived  barriers  that  discourage  

implementation  of  EBP?    

Barriers  Scale  

S  Adopter  mean  2.14  

S  Organiza%on  mean  2.60  

S  Innova%on  mean  2.32  

S  Communica%on  mean  2.45  

Clinical  Question:    What  are  CRNAs’  common  perceived  facilitators  that  encourage  

implementation  of  EBP?    

S  research  

S  costs  

S  access  to  research  

S  prac%ce  seEng  

S  personal  facilitators    

     

Clinical  Question:  Is  there  a  relationship  between  perceived  barriers  to  the  implementation  of  EBP  and  

demographic  variables  (CRNAs’  age,  gender,  ethnicity,  level  of  education,  number  of  years  as  a  

CRNA)?      

S  prac%ce  environments  

S  type  of  primary  job  facility  

S  medical  supervision  

S  independent  contractor  

S  urban  or  rural  loca%on  

S  ease  of  access  to  Internet  for  research  

SigniAicance  

no  sta%s%cal  significance  was  found  in  rela%onships  between    

S  prac%ce  environment/type  of  primary  job  facility    

S  urban  versus  rural  prac%ce  sites  

S  ease  of  access  to  the  Internet  from  research  purposes    

and  each  of  the  BARRIERS  four  Factors  

S  of  the  90  par%cipants  who  answered  the  ques%on,  sixty-­‐two  (68.89%)  stated  they  had  very  easy  Internet  access  

SigniAicance  

S  Sta%s%cally  significant  rela%onships  to  barriers  as  demonstrated  on  the  BARRIERS  to  research  u%liza%on  scale  

S  Adopter  and  number  of  years  as  CRNA  

 r  =  .27,  n  =  69,  p  =  .023  

S  Adopter  and  level  of  educa%on  r  =  -­‐.33,  n  =  69,  p  =  .005  

 Healthcare  and  Practice  

Impact      

S  Implemen%ng  EBP  has  been  shown  to  improve  pa%ent  outcomes  by  28%    

(Wesuall,  Mold,  &  Fagnan,  2007)  

Educational  and  Practice  Impact  Qualitative  Interviews  

S  CRNAs  with  ≥  10  years  experience  less  likely  to  have  a  textbook  defini%on  of  EBP    

 “I  don’t  even  know  what  it  is.  You  need  to  tell  me  what  it  is.”  (>  20  years  experience)    

S  CRNAs  with  <  10  years  experience  gave  textbook  defini%ons  of  EBP  

 “Evidence-­‐based  prac%ce  is  the  use  of  knowledge  from  randomized  control  trials,  reported  in  peer-­‐reviewed  journals.  This  should  guide  your  prac%ce.”  

Implications  for  Further  Research  and  Cost  Impact  

S  replicated  with  larger  sample  

S  collec%on  of  more  detailed  demographic  informa%on  regarding  primary  prac%ce  sites  to  improve  the  strength  of  study  and  increase  applicability    

S  administer  at  individual  prac%ce  sites  to  create  a  plan  for  increased  EBP  use  in  that  par%cular  site  

Questions  

Follow-­‐up  

S  Contact  authors  for  references  and  informa%on  on  studies.  

S  Dr.  Copeland  sandradawg@aol.com    

S  Dr.  Parkman  lparkman@windstream.net