Strategies for Creating an EvidenceBased Practice Nursing Culture

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Strategies for Creating an Evidence-Based
Practice Nursing Culture

• Tanya Feddern
• MLIS, AHIP, MOT, OTR/L
• Kathryn Ewers
• RN, BA, MEd
• Special thanks for layout and graphics
• John D Jones Jr and Sandra Benitez

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• 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 RNAOs
  (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.

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Collaboration
Jackson Memorial Hospital
Louis Calder Memorial Library
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Topic Overview

• EBN Strategic Plan
• Educational Strategies
• Practice Strategies
• Organizational Strategies
• Outcomes
• Challenges
• Future Plans

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Assess Environmental Readiness for Evidence Based
Practice Culture (1)
Resources (3)
Stakeholders (2)
Implementation of Strategies for EBP Culture (4)
Identify Implement EBP Model (5)
Evaluation (6)
Framework for the Strategic Plan EBP Culture
Implementation Model Adapted from RNAO Toolkit
Clinical Practice Guideline Implementation Model
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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

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Timeline for EBN Curriculum

• May 2004 Intro class Finding the
  Evidence-Introduction to EBP as CE Class
  (initially just to Hospital Educators)
• Fall 2004 OVID MEDLINE Tutorial as CE Class
• January 2005 Intro to EBP added to Nursing
  Orientation
• January 2006 Certificate Program in EBN
  Developed
• January 2006 UM Research Certification Class

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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)

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Introduction to EBP Finding the Evidence

• Led by Kathryn Ewers
• Course Objectives
• Goals of EBN
• Types of Evidence
• Introduced EBN model
• Introduced accessing Evidence-Based Resources

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Ovid MEDLINE/CINAHL Tutorials

• Led by Tanya Feddern
• Course 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

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Practice Strategies

• Developed 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

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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

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Barriers to Research Utilization
16.4 Lack of skill accessing/assessing research
41.8 Lack of Time
7 Research Not Valued
11.1 Unaware of Scope of Autonomous Nursing
Practice
23.6 Lack of resources
N1033
14
Resources consulted when participants had a
clinical question
Clinical Practice/Best Practice Guidelines 3.5
Patient 2
Cochrane Collaboration 4
Internet Resources 10
Members of Healthcare Team 49
Textbooks 11
Policies Procedures, Clinical Pathways/Care
Plans 11
Journals 13
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Nursing Knowledge of Evidence Based Practice
Answer to I have .
YES NO
Accessed full text, evidence-based electronic
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
69.8
43.2
56.8
24.9
75.1
58.4
41.6

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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
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EBP Skill PICO Writing
Used the PICO framework to form my research
question P Patient Problem I Intervention C
Comparison O Outcome
12.1
87.9
YES NO
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Journal Consultation Practice Change
Consulted journal article regarding clinical
question Changed practice due to a new research
finding
52.5
15.3
31.7
16.8
21.2
21.3
16.7
15.3
9.1
Within the last 3 months
Within the last 6 months
Within the Last year
Never
More than 2 years ago
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Cultural Context of Leadership

• 85.1 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 managers 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 managers 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

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Survey Conclusions

• Large 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 resources
• Strong commitment to the value of nursing
  research
• Higher rate of practice change based on evidence
• Higher rate of knowledge about EBP
• Comprehensive, collaborative approaches to
  educational strategies for EBP

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Survey Conclusions (continued)

• Pravikoff study
• The 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 study
• The 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

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Focus for Improvement

• Increase utilization of PICO format for
  research
• Develop strategies to increase utilization of
  clinical practice guidelines when nurses have a
  clinical question
• Address nurses perception of lack of time as the
  number barrier to research utilization
• Ensure adequate computer and Internet access
• Develop web page with EBP resources
• Address leadership issues where scores are low in
  cultural leadership context

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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 31317-22.
ASSESS need for change in practice
DEVELOP an answerable research question
EVALUATE
CONSULT best evidence resources
IMPLEMENT
EDUCATE
SYNTHESIZE best evidence
PROPOSE/DESIGN change in practice/policy to go
to relevant committee
STIMULATE inquiry
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Organizational Strategies

• Dovetailed Magnet EBP activities
• Marketing - Nurse Week Activities
• Pursued International Center Membership with RNAO
• Nursing Vision and Strategic Goals include EBP
• Nursing strategic goals aligned with Corporate
  Vision and goals
• Partnered with academic centers
• Web page development
• Developing Unit-Based Practice Councils
• Recruited JHS nurses for Sigma Theta Tau
  membership

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Nurse Week May 2005
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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 increase
• 1,067 in 2004
• 14,367 in 2005
• Several JHS nurses appointed as adjunct UM
  Nursing Faculty

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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.

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CINAHL session searchesCumulative Index Nursing
Allied Health Literature
14,367
1,067
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Practice Outcomes

• Policy 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

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Organizational Outcomes

• Nursing Vision and Strategic Goals endorse
  evidence-based practice and global leadership in
  evidence based practice
• Anticipated improvement in quality of care and
  patient outcomes
• Anticipated improvement in nurse satisfaction
• More respect for nurses knowledge
• ANA Magnet Standards met for EBP
• JHS Nursing featured in local and international
  nursing publications
• Interdisciplinary interaction and CEs (nurses,
  RTs, Pharmacists)
• Increased collaboration between UM JHS

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Challenges

• Time constraints- compressing class content
• Coordinating schedules
• Time Resources for Marketing
• Content modifications of CE materials from
  physicians to allied health
• Competing Corporate Agendas
• Managing contact hours and paperwork
• MyMedEd accessible only to JHS Staff
• Computer literacy variability

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Future Strategies

• University-based listservs on EBP for Jackson
  Memorial Hospital (JMH) nurses
• On-line/self study Course Development
• On-line journal clubs
• JHS webpage on research and EBP for nurses
• Target utilization of EBN Model to Unit Based
  Councils for initiating practice change
• Provide CEUs for Occupational Therapy, Pharmacy
• Tie Clinical Advancement Ladder to EBP Education
• Joint Conference offerings with RNAO, UM, JHS
• Collaborating with the UM nursing school and
  nurse librarian to create a continuity of EBP
  instruction and knowledgefrom the nursing school
  curriculum to the hospital

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Thank You

• Tanya Feddern
• Reference Education Services Librarian
• Louis Calder Memorial Library,
• University of Miami Miller School of Medicine
• tfeddern_at_med.miami.edu
• 305-243-6648
• Kathryn Ewers
• Nursing Educator
• Jackson Memorial Hospital in Miami, Florida
• kewers_at_um-jmh.org
• 305-585-7134

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References

• CITI Course in the Protection of Human Research
  Subjects https//www.citiprogram.org/citi_informat
  ion.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.

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Further Reading

• Brown 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.