Strategies

to

Implement

EBP

Evidence-

Based

Decision

Making

Organizati

onal

Infrastruc

ture

Quality

Patient

Care

Marita G. Titler, PhD, RN, FAANMarita G. Titler, PhD, RN, FAANSenior Assistant Director, University of Iowa Hospitals and Clinics

Director, Research, Quality and Outcomes ManagementDepartment of Nursing Services and Patient Care, UIHC

Director, Institute of Translational Practice, Center for Research in the Implementation of Innovative Strategies in Practice,

Department of Veterans Affairs

Laura Cullen, MA, RN, APNLaura Cullen, MA, RN, APNEvidence-Based Practice Coordinator

Research, Quality and Outcomes ManagementDepartment of Nursing Services and Patient Care, UIHC

Educational Educational Strategies for Strategies for

CliniciansClinicians

ObjectivesObjectives

To overview two educational programs for staff that address promoting use of EBPs

• Staff nurse internship for EBP

• Advanced Practice Institute for EBP

• Others we have Nurse Managers Senior Leaders

The EvidenceThe Evidence

Nurses at the point of care delivery are in the ideal position to ask & answer clinical questions

Need strategies that link clinicians with evidence

Several steps in the EBP process are challenging

Application oriented approach with active facilitation is necessary to learn the process

Cullen & Titler, 2004; Ellis, Howard, Larson & Robertson, 2005; Estabrooks, Chong, Brigidear & Profetto-McGrath, 2005; Estrabrooks, Rutakumwa, O’Leary, Profetto-McGrath, Milner, Levers & Scott-Findlay, 2005; Fink, Thompson & Bonnes, 2005; Johnson & Mighten, 2005; Pravikoff, Tanner & Pierce, 2005; Robertson, Umble & Cervero, 2003; Schultz, Whiting, Kent, Keane & Gallant, 2004; Thomson O’Brien, Freemantle, Oxman, Wolf, Davis & Herrin, 2001; Waddell & Dunn, 2005

The Evidence (con’t)The Evidence (con’t) Complex skills are needed for leading EBP

initiatives

Leadership is essential for success

Evidence-based practice work must be resourced to succeed

Translation research is a young/growing science; use of effective strategies for implementation is not broadly understood

Berwick, 2003; Greenhalgh, Robert, Bate, Macfarlane & Kyriakidou, 2005; Kirchhoff, 2004; Ravaud, Keïta, Porcher, Durand-Stocco, Desmonts & Mantz, 2004; Rogers, 2003; Schultz, Whiting, Kent, Keane & Gallant, 2004; Simon, Majumdar, Prosser, Salem-Schatz, Warner, Kleinman, Miroshnik & Soumerai, 2005; Thomson O’Brien, Oxman, Davis, Haynes, Freemantle & Harvey, 1997; Titler, Cullen & Ardery 2002; Titler & Everett, 2001; Tranmer et al, 1998; Van Mullem et al, 1999

AudienceAudience

Staff nurses

• Evidence-Based Practice Staff Nurse Internship

Nursing leaders

• Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice

Strategies

to

Implement

EBP

Evidence-

Based

Decision

Making

Organizati

onal

Infrastruc

ture

Quality

Patient

Care

Evidence-Based Practice Evidence-Based Practice Staff Nurse InternshipStaff Nurse Internship

PurposePurpose

Stimulate innovative thinking about efficient and effective practices to improve patient outcomes

Use the Iowa Model of Evidence-Based Practice to Promote Quality Care

Assist staff nurses with application of the evidence-based practice process

Foster professional growth and development of staff nurse interns at UIHC

Course OverviewCourse Overview

Pilot program 2001

Funding

Mass mailing of brochures

Basic eligibility criteria

Simple application

Signed contract

Competitive review process

18 month program

12 meetings/year

Facilitated work time

Staff nurse, APN, & NM teams

Administrative support

Free CEUs

ScheduleSchedule

Day 1: Understanding the Iowa Model

Day 2: Application of the Iowa Model and The Translation Research Model

Day 3: Synthesis of the Evidence

Day 4: National Evidence-Based Practice Conference

Days 5-12: Implementation & Evaluation

Expectations of InternsExpectations of Interns Process

• Full participation in and completion of the coursework• Regular meetings with the leadership team• Work with appropriate committee in developing the

practice protocol (e.g., Professional Nursing Practice committee)

Project Outcomes• Development, implementation and evaluation of one

project• Dissemination of project results

Peer Influence• Promote use of evidence to guide practice• Promote change in the clinical area

List of ProjectsList of Projects Pet visitation

Suicide risk assessment

Sedation management

Guided imagery

Bowel sound assessment

NG placement for children

Enteral feeding

Occipital pressure ulcers

OR handscrub

Fall risk assessment

Double gloving

Family transfer from PICU

Dietary restrictions

Patient education for otological procedures

Communicating end-of life wishes

New Cohort 2007New Cohort 2007

Pediatric Palliative Care

Bedside Swallow Screen

Blood Pressure Monitoring

Psychiatric Advanced Directives (PADs)

Sleep Deprivation

Thermoregulation of High Risk Neonate

Perineal Dermatitis

http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/internship.html

Evaluation – initial cohortEvaluation – initial cohort

Evaluation of the course content by attendee

Critique of the program by NM, APN and staff nurse with recommendations for improvement

Completed implementation and evaluation of an evidence-based practice project, including dissemination

Performance evaluation to include participation and outcomes of the program

Evaluation Results: Evaluation Results: QualitativeQualitative

“I know the knowledge-based for the cutting edge information of EBP”

“The opportunity for professional growth has been provided”

“Recognition that the STN observes situations/topics which need to be changed and receiving support to do this”

“I think integrating this into nursing will be a huge plus, not only for UIHC but nursing.”

“It has given me a huge self-esteem boost and I hope this internship continues for more and more nurses.”

--Intern feedback, June 2001

Focus Group Feedback – Focus Group Feedback – Initial cohortInitial cohort

Staff Nurses

Motivated by change

Partnership was critical

Time

Opportunity for growth

Coordination

Class content revisions

Mentorship

Nurse Managers

Time

Coordination

Mentorship

Dissemination of results

Application process

APNs

Time

Partnership for resourcing

Coordination

Growth opportunity

Program revisions

Final EvaluationFinal Evaluation

4.5 4.5 4.64.4

1

2

3

4

5

Understand process @ UIHC Professional Growth

Understand IA Model Stimulate innovative thinking

*n = 16; 2002-06 combined data

Strongly Disagree

Strongly Agree

Interns’ Additional CommentsInterns’ Additional Comments “This program is a wonderful opportunity for STNs

to make a difference” -- Intern feedback, February 2002

“I have had the idea for the project for a long time. I didn’t know how to proceed or how to get the support I needed. The internship provided both for me”. -- Intern feedback, May 2003

“I feel that I will get more out of this then I could ever put into it”!! -- Intern feedback, May 2003

“I think the more skilled the mentor in EBP, the more productive the project becomes.”

-- Intern feedback, February 2006

Keys to SuccessKeys to Success

Topic selection by STN’s

Competitive review of applications

Paid release time from clinical responsibility

Summer and holiday schedule

Regularly scheduled work sessions

Matching clinical, systems and EBP expertise

Beginning work sessions with a project update, troubleshooting & team building

Project IntegrationProject Integration

Sustaining the projects is a priority (STN feedback; NM focus group feedback, February 2002)

Process involves:

• Reporting results to the Nursing Research Committee

• Development of QI goal and monitoring

• Development of education (orientation, competency review, temporary staff, etc.)

• Revisions in documentation to support practices

• Reporting results to Nursing QM Committee

Staff Nurse RecognitionStaff Nurse Recognition

Celebrate SuccessCelebrate Success

AwardsAwards

Sigma Theta Tau International EBP Award

UIHC People’s Choice Award

AORN Poster Award

Colleen Goode EBP Poster Award

UIHC Recognition Day Poster Award

SummarySummary

Empowering for STN’s• Staff felt valued & gained confidence• Recognition for a job-well-done

Networking across department and multidisciplinary

Evaluations led to program revisions

Support from APN/NM mentors & research office is critical

Positive impact on outcomes

Strategies

to

Implement

EBP

Evidence-

Based

Decision

Making

Organizati

onal

Infrastruc

ture

Quality

Patient

Care

Advanced Practice Institute: Promoting

Adoption of Evidence-Based Practice

Goals and PurposeGoals and Purpose

To promote advanced skills of nursing leaders in use of evidence-based practice models.

To develop leadership skills for facilitating completion of clinically relevant evidence-based practice projects.

To foster networks for creative thinking and issue resolution in the evidence-based practice process.

The purpose of the Institute is to educate nursing leaders to guide colleagues and staff in the integration of evidence-based knowledge into practice.

ObjectivesObjectives Identify strategies for implementing

and sustaining evidence-based practice changes in complex health care systems.

Describe the organizational infrastructure necessary for evidence-based practice.

Utilize the toolkit provided to promote evidence-based practice.

Train other nurses in the evidence-based practice process.

Develop a specific evidence-based practice clinical topic.

OverviewOverview

Three day intense workshop

Prerequisite preparation and homework

Limited group size

Small group and individual consultations

Application oriented

Emphasis on most challenging steps

PrerequisitesPrerequisites

Overview of Iowa Model

• Readings

• Web-based CE course

Addressing challenges in EBP

• Readings

Critique research articles

ScheduleSchedule

Day 1:

• Topics and teams

• Locating, critiquing and synthesizing the evidence

• Building an implementation plan

Day 2: Implementation and Evaluation

Day 3:

• Sustaining change

• Roles and project exemplars

• Building the infrastructure and program

Expectations and ResourcesExpectations and Resources

Apply information shared and project developed during Institute

Complete an EBP project

Develop leadership skills for facilitating EBP within their organization

Receive Toolkit and extensive resources for their project and EBP process

Consultation on-site and after the program

EvaluationEvaluation

100% 100% 98% 100%

0%

20%

40%

60%

80%

100%

Identify strategies for implementation Discuss methods for sustaining EBP

Train other nurses in EBP Begin develop. EBP project

EvaluationEvaluation

4.94.7 4.6 4.8

1

2

3

4

5

Understand EBP steps Enables develop EBP initiativePrepared to lead initiative Discussions were helpful

Additional CommentsAdditional Comments

“This was the best workshop I’ve ever attended.” “I was in awe of the level of expertise and education

of the faculty. It was very impressive to see what you have accomplished.” -2003

“Immersion into the ‘world’ of EBP, the tremendous overview and detail gave me what I need to support my organization as it evolves in this excellent method of care delivery.” -2003

“This was an awesome experience-really feel I can proceed with my project now and succeed.” -2005

Additional CommentsAdditional Comments

“The energy in the room was great both with the participants and instructors-as well as the staff nurses who presented. It was great to have people enthusiastic about improving patient care. I found this so refreshing because nurses historically put down other nurses and frequently stagnate other nurses. This was the complete opposite-nurse helping nurses-what a novel idea. All nurses should take this course-period! Administrative and clinical.” -2004

“This was the best group I have been involved with in a long time. The expertise and sharing was fabulous.” -2006

Keys to SuccessKeys to Success

Small group of participants

Application oriented

Emphasis on implementation and other most challenging steps

Networking opportunity

Extensive number of useful resources

Project focused consultation and work time

Large group of expert faculty and consultants

Long-Term Program Long-Term Program EvaluationEvaluation

Questionnaire:• Sent January 2007• Program attendees from 10/02-3/06 at UIHC• Response rate = 33/94 (35.1%)

Respondents:• 2/3 attended 1-1 ½ years prior • Mean 2 years since attending the Institute

Program ImpactProgram Impact

Institute was helpful in addressing challenges (mean 4.1 on 1-5 scale; 85% agree or strongly agree)

Project completion:• 30% completed their project• 42% still working on their project• 36% working on a different project

Outcomes:• Patient impact (79%)• Staff impact (67%)• Fiscal impact (39%)• Other: “I truly believe we would not have received Magnet

status without the tools from Iowa to establish EBP here.”

Program ImpactProgram Impact Shared knowledge gained from the Institute (100%)

Made changes within organizational infrastructure (82%)

Developed strategies for expanding EBP within their organization (91%)

Have formal responsibility for EBP within a specific role or committee (65%)

Application of Application of Program ContentProgram Content

4.6 4.6 4.6 4.5

1

2

3

4

5

Prepared me to complete project Prepared me to lead EBP initiativesProgram manual was valuable Slides provided were valuable

Mastery of Advanced SkillsMastery of Advanced Skills Data collection for project evaluation (3.72)

Planning the pilot (3.69)

Managing a team (3.69)

Developing an action plan (3.66)

Modifying practice recommendations based on pilot (3.66)

Developing an evidence-based practice policy (3.64)

Prioritizing topics (3.58)

Rated on 1-4 scale; not able to completely able

ImplicationsImplications

Facilitation is essential

Educators: Develop academic and continuing education to promote skill development• Evidence: locating, critique, analysis & synthesis• Data interpretations: statistical process control charts• Evidence promoting sustainability of EBP changes

Leadership: Develop capacity, support, expectations and commitment to the journey

SummarySummary

EBP work can be challenging

Unique educational strategies are needed

Distinct programs address audience learning objectives (e.g., basic and advanced)

Programs can be successful using a learn by doing approach with sufficient facilitation

Evaluations are positive and healthcare outcomes improve

Is Practice Based on Evidence?Is Practice Based on Evidence?

TRADITION

InternshipInternship:: Cullen, L. & Titler, M.G. (2004). Promoting evidence-based practice: An internship for staff nurses. Worldviews on Evidence-Based Nursing,1(4), 215-223.

Institute:Institute: http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/apinstitute.html

Additional Reflections Additional Reflections

Demand is high

Nurse driven interdisciplinary improvement of care delivery

Return on investment is good

Mentorship at the organizational level• ANMC• St. Cloud, Minn.

Interdisciplinary program

Intensive yet fun