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Strategies for Creating an Evidence-Based Practice Nursing Culture

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. Project Abstract

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Strategies for Creating an Evidence-Based Practice Nursing Culture

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  1. 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

  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. 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 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 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 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 Objectives • Goals of EBN • Types of Evidence • Introduced EBN model • Introduced accessing Evidence-Based Resources May 22, 2006 MLA Annual Conference

  10. 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 May 22, 2006 MLA Annual Conference

  11. 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 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 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 N=1033 May 22, 2006 MLA Annual Conference

  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% May 22, 2006 MLA Annual Conference

  15. 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% % 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 besystematic reviews and meta-analyses. The best way to define evidence-based/best practice isutilization 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 Problem I = Intervention C = Comparison O = Outcome 12.1% 87.9% YES NO 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 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 May 22, 2006 MLA Annual Conference

  19. 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 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 Conclusions • Large practice gap between accessof 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 May 22, 2006 MLA Annual Conference

  21. 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% Survey Conclusions (continued) May 22, 2006 MLA Annual Conference

  22. 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 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. 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 May 22, 2006 MLA Annual Conference

  24. 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 May 22, 2006 MLA Annual Conference

  25. Nurse Week May 2005 May 22, 2006 MLA Annual Conference

  26. 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 Educational Outcomes 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 14,367 1,067 May 22, 2006 MLA Annual Conference

  29. 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 May 22, 2006 MLA Annual Conference

  30. 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 May 22, 2006 MLA Annual Conference

  31. 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 May 22, 2006 MLA Annual Conference

  32. 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 CEU’s 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 knowledge—from the nursing school curriculum to the hospital May 22, 2006 MLA Annual Conference

  33. Thank You • Tanya Feddern Reference & Education Services Librarian Louis Calder Memorial Library, University of Miami Miller School of Medicine tfeddern@med.miami.edu 305-243-6648 • Kathryn Ewers Nursing Educator Jackson Memorial Hospital in Miami, Florida kewers@um-jmh.org 305-585-7134 May 22, 2006 MLA Annual Conference

  34. References CITI: 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 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. May 22, 2006 MLA Annual Conference

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