Implementing and Barriers for EBP

Scorecards

Balanced scorecards are used to show how indicators from different areas may relate to each other. Typically, scorecards are used to indicate performance over a single year Scorecard indicators can include (a) identifiers of high-level strategic initiatives; (b) objectives linked to the organizational strategic plan, making the outcomes relevant across the organization; (c) the measures or metrics for each outcome; and (d) indicators of how things are going, usually in relation to given expectations or standards, often using colors.

Assess and Eliminate Barriers

Barrier assessment is an integral component throughout the engagement and integration phases of EBP implementation. Stakeholder resistance to change must be explored early, because it frequently results from numerous factors including hesitation to break traditional practice, unfamiliarity with how evidence will improve patient outcomes, or misconceptions regarding time and effort needed to implement practice change. Engage staff and stakeholders in assessing and eliminating barriers • Engage stakeholders to identify educational content and strategies to learn about the practice change. • Seek information about attitudes toward the affected practice directly from staff. • Involve influential staff and leaders in conducting discussions with colleagues. Prioritize clinical issues • Select clinical issues of direct interest and responsibility of clinician stakeholders. • Choose issues with solid empiric evidence to begin an organizational area's EBP endeavors Evaluate the infrastructure • Determine the individuals and committees with decision making authority. • Gain administrative support for adequate time and personnel for the initiative. • Enlist experts to lead EBP initiatives. • Ensure access to databases, search engines, and full-text articles. Develop experts in the evidence-based process • Utilize leaders within the organization or form an academic partnership to provide expertise in research, EBP design, and evaluation. • Provide formal classes and/or small-group sessions on finding and evaluating evidence. • Mentor staff in critically appraising research studies and formulating practice recommendations.

Sources of Internal Evidence Clinical Systems

-These systems may house test results such as laboratory tests or point-of-care tests. -They may also house pharmacy data such as numbers of doses of a medication or types of medications, which may be used to evaluate care process compliance or evaluate relationships among different medications and patient outcomes. -In some organizations, the clinical system is the source of data for reporting outcomes in integrated reviews, such as dashboards

eys to accomplishing a successful vision include:

-preparation and planning While increased knowledge and understanding are important to any EBP initiative, a key to changing actual behaviors is ownership of change.

National Strategy for Quality Improvement what are the 3 aims?

1. Better Care: Improve the overall quality of care by making healthcare more patient-centered, reliable, accessible, and safe. 2. Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher quality care. 3. Affordable Care: Reduce the cost of quality healthcare for individuals, families, employers, and government.

EBP Vision: Transforming a Clinical Environment

1. Develop a mental framework • Develop a written summary of what you want to accomplish. • Brainstorm with colleagues regarding the environment you want to create 2. Establish a motivating image for change • Use creativity to capture attention of the clinical staff. • Take advantage of real clinical scenarios to stress the need for changes in practice. 3. Create specific goals • Focus on short-term, attainable goals. • Establish only two to three goals at a time. 4.Gain administrative support • Contact administrators responsible for clinical practice. • Create a presentation that reflects the need for transforming the culture into an EBP environment. • Seek administration support for the project to be identified as an organizational priority. 5. Establish a leadership team • Identify key personnel with a passion for EBP. • Conduct small focus group meetings 6. Involve experts and EBP mentors in clinical practice • Identify clinical experts and EBP mentors focused on the area. • Engage clinical expert support.

Innovative leaders

Are those individuals who create an infrastructure that weaves innovation into the DNA of their organization. Within a culture of innovation, employees are both empowered and encouraged to challenge the status quo and integrate new processes and technologies into the organization so that systems operate more effectively and efficiently. Innovation and risk-taking were not traditionally viewed as positive attributes of a healthcare leader. More emphasis was placed on continuing routine practices that were predictable and worked yesterday, or reworking ineffective processes, rather than taking initiative to advance innovation and move the organization to the desired future Competencies for innovative leaders: Assessment for innovation: personal knowledge of one's propensity, ability, and skill with innovation work Future-focused: actively plans for a better future and understands the value of change Value-driven: believes new ideas will advance performance and value

Authentic leaders

Authentic leaders are described as individuals who are confident, hopeful, optimistic, resilient, transparent, and possess high moral character. These leaders demonstrate self-awareness; they are aware of how they think and behave. They have a keen sense of who they are and where they stand on issues, values, and beliefs Authentic leaders are role models and focus on the ethical and right thing to do. The development of others is a priority, and they work to ensure that their communication is transparent and comprehended as intended Followers perceive them as having an intense awareness of their own and others values, moral perspectives, knowledge, and strengths Authentic leaders are able to create and sustain high-quality relationships with their followers via personal identification, which results in enhanced engagement, increased motivation, commitment, and job satisfaction The authentic leader is uniquely poised to lead the transition to an EBP culture through role modeling of EBP, engaging and motivating their teams to adopt best practices, and enthusiastically celebrating delivery of the best and most ethical care possible for patients

implementation process

Build Excitement While Integrating EBP into the Clinical Environment Build excitement for EBP • Demonstrate the link between proposed EBP changes and desired patient outcomes. • Build a "burning platform" (i.e., a passionate, compelling case) to drive change. • Create a level of discomfort with status quo by sharing evidence of better outcomes at other healthcare settings. Establish formal implementation teams • Integrate experts in change theory at the systems level, such as advanced practice registered nurses. • Include expert staff members to ensure clinical applicability, feasibility, and adoption into practice. • Exhibit passion for the practice change. • Enlist local opinion leaders who can attest to the need for practice change. • Bring in outside speakers who have the potential to connect and inspire key stakeholders. • Create discomfort with status quo. Disseminate evidence • Utilize multifaceted strategies to overcome knowledge deficits, skill deficits, and skepticism. • Promote experience sharing to emphasize the need for change and positive outcomes of change. • Provide time to assimilate new practices. Develop clinical tools • Anticipate tools and processes that the staff will need to transform practice. • Revise patient care documentation records. • Ensure easy access to clinical resources. • Integrate alerts and reminders into workflow processes at the point of care. • Repeatedly expose the staff to evidence-based information. Pilot the evidence-based change • Choose pilot sites with consideration to unit leadership strength, patient population diversity, acuity, and geographic location. • Address the root causes of problems. • Decide to adopt, adapt, or abandon at the end of the pilot. Preserve energy sources • Engage support personnel. • Implement smaller, more manageable projects. • Anticipate setbacks and be patient and persistent. Allow enough time to demonstrate the project's success • Develop incremental project steps. • Establish a timeline. Celebrate success • Acknowledge the staff instrumental in the process. • Ensure recognition by supervisors and administration. • Recognize the staff in presentations.

Types of data

Categorical variables are those that are grouped due to a defined characteristic, such as gender, presence or absence of a disease, or possession of particular risk factors. Numbers are commonly used to label categorical data --scales, which allow ranking of data (e.g., not at all, somewhat, moderately so, very much so), are also categorical in nature in that they group data by ranks. However, data analysts often consider these types of scales numerical. Generally, the statistical methods used to analyze categorical data are frequencies Numeric data potentially have an infinite number of possible values, such as measures for height, weight, mean arterial pressure, and heart rate. Unlike categorical data, the mathematical intervals that separate numeric data are equal. For example, the interval between the numbers 20 and 21 is equal to the interval between 21 and 22, namely 1

Patient-Centered Quality Care

Crucial to promoting patient-centered quality care is open, honest discussion of the illness or disease. •Consideration of the cultural and religious beliefs of the patient and family, being respectful and considerate, nonavoidance of specific issues, empathy, patience, and a caring attitude and environment are all important. •Use of measures that critically evaluate key aspects of patient-centered quality care within a healthcare organization can provide crucial evidence that differentiates a good healthcare setting from an outstanding one. •Busy hospital environments often prevent family coping strategies from effectively being utilized even though evidence supports the importance of family presence. •Time constraints often prevent patient-centered quality care.

Sources of Internal Evidence Human Resources

Data housed in human resource departments generally include those generated from employee and payroll systems. Data generated by employee systems include turnover and staff education levels. Data available from payroll systems include hours by pay category or labor category and contract labor use. In some organizations, contract labor use and expense may be housed in financial systems used for expense reporting. Hours by labor category may be used to calculate provider skill mix. Hours by pay category may be used to calculate staffing.

Four dimensions comprise transformational leadership, including

Idealized influence—serves as role model for followers and builds respect and trust. The focus is on doing things right rather than ensuring that their followers do the right things Inspirational motivation—articulates a clear vision for followers and is charismatic. She or he infuses enthusiasm and optimism, and inspires and motivates others to accomplish great achievements Intellectual stimulation—encourages innovation and creativity; empowers followers to explore new ways of doing things and approach problems using EBP Individualized consideration—provides support and encouragement for followers; offers rewards and recognition to individuals for their unique contributions

EBP Evaluation in the Clinical Environment (Objectives and Measurement description)

Outcome measures Outcome measures are defined as those healthcare results that can be quantified-- Outcomes such as health status, death, disability, iatrogenic effects of treatment, health behaviors, and the economic impact of therapy and illness management. Evaluate changes in clinical practice, support healthcare decision-making, and establish new policies or practice guidelines. Quality care improvement -Further quantifying how interventions affect the quality of life of patients and families Examples of health-related quality of life measures include symptom burden such as pain, fatigue, nausea, sleep disturbances, and depression caused by many acute and chronic diseases and improving self-perception, sense of well-being, and social participation. Patient-centered quality care -These measures are defined as the value patients and families place on the healthcare received. Patient-centered quality care requires a philosophy of care that views the patient as an equal partner rather than a passive recipient of care -Measures include effective communication with healthcare personnel; open, unrushed interactions; presentation of all options for care; open discussion of the illness or disease; sensitivity to pain and emotional distress; consideration of the cultural and religious beliefs of the patient and family; being respectful and considerate; nonavoidance of specific issues; empathy; patience; equitable access and treatment; and a caring attitude and environment. Efficiency of processes -As healthcare organizations become more sophisticated in evaluation strategies, it becomes essential to evaluate the efficiency of healthcare delivery processes. Leads to excellence in care and cost containment -Optimal timing of interventions, effective discharge planning, elimination of waste such as duplication of tests, and efficient utilization of hospital beds are exemplars of efficiency of processes indicators. Environmental changes -Environmental change evaluation reflects the creation of a culture that promotes the use of EBP throughout the organization. Environmental outcome measures are uniquely different in comparison with the efficiency of processes in that a process can change or patient outcomes change, yet there is no impact on the environment. This difference is often observed with policy and procedure changes that are carefully updated and filed into procedure manuals, yet no practice changes actually occur in the clinical setting Evaluation of policy and procedure adherence, unit resource availability, and healthcare professional access to supplies and materials essential to implement best practices. Professional expertise -Excellence in providing the best possible healthcare cannot occur without expert providers. Increasing sophistication in healthcare technology places significant demands on institutions to employ healthcare professionals with appropriate expertise -Professional expertise promotes excellence by establishing expectations for adherence to accepted standards of care essential for best practice.

Sources of Internal Evidence Electronic Health Records

Meaningful use refers to using data from the EHRs to improve healthcare quality and outcomes. Data may include patient-level information, such as vital signs and weights, non-charge-generating clinical interventions (e.g., indwelling urinary catheter use) or essentially any data element captured through documentation of clinical care.

Competencies for Practicing Registered Nurses and Advanced Practice Nurses

Questions clinical practices to improve the quality of care. Describes clinical problems using internal evidence.* Participates in the formulation of clinical questions using PICOT* format. Searches for external evidence† to answer focused clinical questions. Participates in critical appraisal of preappraised evidence (such as clinical practice guidelines, evidence-based policies and procedures, and evidence syntheses). Participates in the critical appraisal of published research studies to determine their strength and applicability to clinical practice. Participates in the evaluation and synthesis of a gathered body of evidence to determine its strength and applicability to clinical practice. Collects practice data (e.g., individual patient data, quality improvement data) systematically as internal evidence for clinical decision making in the care of individuals, groups, and populations. Integrates evidence gathered from external and internal sources to plan EBP changes. Implements practice changes based on evidence, clinical expertise, and patient preferences to improve care processes and patient outcomes. Evaluates outcomes of evidence-based decisions and practice changes for individuals, groups, and populations to determine best practices. Disseminates best practices supported by evidence to improve quality of care and patient outcomes. Participates in strategies to sustain an EBP culture. Evidence-Based Practice Competencies for Practicing Advanced Practice Nurses All competencies of registered professional nurses AND Systematically conducts an exhaustive search for external evidence‡ to answer clinical questions. Critically appraises relevant preappraised evidence (i.e., clinical guidelines, summaries, synopses, syntheses of relevant external evidence) and primary studies, including evaluation and synthesis. Integrates a body of external evidence from nursing and related fields with internal evidence** in making decisions about patient care. Leads transdisciplinary teams in applying synthesized evidence to initiate clinical decisions and practice changes to improve the health of individuals, groups, and populations. Generates internal evidence through outcomes management and EBP implementation projects for the purpose of integrating best practices. Measures processes and outcomes of evidence-based clinical decisions. Formulates evidence-based policies and procedures. Participates in the generation of external evidence with other healthcare professionals. Mentors others in evidence-based decision making and the EBP process. Implements strategies to sustain an EBP culture. Communicates best evidence to individuals, groups, colleagues, and policy makers

Run Charts Bar graphs

Run charts are line charts that display data change over time To develop a run chart, first determine the time to be displayed along the x-axis (horizontal line). Along the y-axis (vertical line), the values for the measure of interest are plotted at the selected time intervals. A goal line can also be added to show how close to attainment the initiative is over time.

Transitioning EBP into practice Using the Model for Improvement

Selection of a strong team of individuals is crucial for the success of any type of change project. The team must consist of individuals from varying roles and disciplines with the knowledge, skills, and commitment to facilitate organizational change

Servant leadership

Servant leadership is both a leadership philosophy and a set of leadership behaviors based on the essential elements of trust, empathy, caring, and focus on others A servant leader shares power and focuses on the growth and well-being of their followers, allowing them to reach their full potential and perform to their highest level. leadership is measured not by the accumulation of exercise of power by one individual at the top of a hierarchy but rather by whether those being served develop as individuals to become more autonomous, independent, wiser, healthier, and likely to become servant leaders themselves. The servant leader can develop an EBP culture and environment by leveraging their rich relationships with individuals in the organization to build teams with strong beliefs in the value and importance of EBP. servant leaders are uniquely poised to cultivate committed EBP champions who perform at their highest level and encourage others to follow in their pursuit of excellence. Those who are led by servant leaders are proposed to reach their full potential and perform optimally

IMPLEMENTING THE EBP COMPETENCIES IN CLINICAL SETTINGS

The EBP competencies should be: -Presented as an expectation of all clinicians, managers, and leaders in their orientation/onboarding -Imbedded in clinical job descriptions and performance reviews to support the expectation that meeting the EBP competencies is not an option; it is a requirement of practice -An expectation for clinicians responsible for development and/or review of clinical policies and procedures, the underpinnings of practice Integrated into the role expectations of clinical preceptors to reinforce expectations delineated during onboarding/orientation; -Included in clinical ladder programs to reflect progressive expectations for clinicians pursuing practice advancement opportunities; it also can be used as an incentive to encourage clinicians to become more skilled in EBP

Transformational leadership

Transformational leadership is defined as a state in which leaders and followers "find meaning and purpose in their work, and grow and develop as a result of their relationship" Because of this relationship, leaders and followers become partners in pursuit of a common goal. Transformational leaders are energetic, compassionate, and enthusiastic. They have the ability to provide a vision, motivate, and inspire others. As a result, followers gain trust in, admiration of, and respect for their leader The environment created by transformational leaders is change oriented, supportive of new ideas, innovative, and open These leaders have the ability to direct change in the organization via their ability to create a supportive infrastructure and empower staff to incorporate evidence into practice they create a culture where staff can be creative, innovative, and open to change uniquely able to create and sustain environments where EBP can thrive by leveraging the deep trust-based relationships they have cultivated at multiple levels across the organization.

following are examples of available data:

Use of specific medications • Timing of antibiotics • Specific patient education • Targeted discharge instructions In addition, data on the following outcomes are also collected: • Fall rates • Catheter-related infections • Urinary tract infections • Pressure ulcer rates and stage progression

Measurement Accuracy: Establishing Validity and Reliability

Validity Validity indicates that the measure or instrument actually measures what it is supposed to measure Reliability Reliability means that an instrument will measure the construct consistently every time it is used.

Sources of Internal Evidence Quality Management

data from the quality management, finance, and human resource departments; clinical systems; administration; and electronic health records (EHRs) Quality Management Quality management departments house data generated from incident reports, which may include falls, sentinel events (i.e., an unexpected event that culminates in death or serious injury), medication errors, and near misses (i.e., an event that could have resulted in harm but was corrected prior to it occurring). -These types of data may be examined for trends related to types, locations, or other factors associated with care process errors, or they may be correlated with structural indicators such as staffing patterns (e.g., number of nurses scheduled to work). -Other types of data that may be housed in quality management are patient satisfaction results and data collected through chart reviews submitted to regulatory or accreditation bodies.

Effective barrier assessment includes

discerning knowledge, attitudes, and beliefs of mid-level and upper-level administrators surrounding practice change and their perceived roles in communicating support for this change. Peer group discussions can be very influential, and informal leaders may weigh in even stronger than formal leaders on whether practice change will actually occur.

Staff and Stakeholders to Engage at All Levels Common barriers to EBP implementation include?

•Staff clinicians •Leadership team members (e.g., executives, administrators) •Advanced practice registered nurses •Stakeholders of all disciplines directly affected •Physicians •Family advisory board •Allied health professionals •Doctorally prepared nurse researchers •Evidence-based practice mentors Barriers Inadequate knowledge and skills, weak beliefs about the value of EBP, lack of EBP mentors, social and organizational influences, and economic restrictions Lack of knowledge and skills can create barriers to daily evidence-based care owing to inadequate understanding of EBP principles, unawareness of how evidence will improve patient outcomes, and unfamiliarity with how to implement change. The best evidence-based policies are of no value to the patients when the staff lack knowledge of how to implement them in practice; the right information must be in the right place at the right time and presented in a meaningful way Lack of EBP mentors in the environment can also be a barrier to implementing EBP by point-of-care staff. Mentors who have in-depth knowledge and skills in both EBP and individual and organizational change strategies are also a key strategy for sustaining change once it is realized. Social and organizational barriers to change include lack of support by leaders, disagreement among clinicians, and limited resources to support change

Quality improvement (QI) is broadly defined as

"a data-driven approach by which individuals work together to improve specific internal systems, processes, costs, productivity, and quality outcomes within an organization

AONE emphasizes that leaders must be innovative and competent in five domains of practice:

(1) communication and relationship management (2) knowledge of the healthcare environment (3) leadership (4) professionalism (5) business skills and principles.

Sources of Internal Evidence Finance

--Examples of these types of data are charges for tests, medications, equipment or supplies, patient days, readmission rates, and patient demographics such as name, age, ethnicity, gender, and nursing unit. --Other data frequently housed in finance departments are codes for patient diagnosis, including Medicare-Severity Diagnosis Related Groups (MS-DRG) and International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD-10) codes. -These types of data are routinely used to measure patient volume, to understand care processes (types of medications used or tests done), or to risk-adjust for patient outcomes. They may also be used to evaluate the incidence of errors within certain patient populations

Some of the EBP barriers that healthcare leaders can address easily within their scope of authority and responsibility include the following:

-Arranging EBP education/skill-building opportunities so that clinicians meet the EBP competencies -Prioritizing operational budgets to include EBP resources -Revamping job descriptions and performance evaluation tools to reflect EBP expectations -Integrating EBP deliverables into clinical ladder requirements -Rewriting the organizational vision and mission statement with clear EBP language included -Reorganizing traditional reporting structures to better align the organization with the EBP paradigm -Creating dedicated EBP mentor positions into which individuals are hired who have robust EBP knowledge and skills in the steps of EBP as well as individual behavior and organizational change theory.

Leadership Styles and Theories Theoretical models of relationship-based leadership include:

-Many leadership theories exist, there are several that are particularly relevant to contemporary healthcare leadership -These models of leadership focus on the relationship between the leader and the follower to achieve a common goal. In these relationship-based theories, the leader creates an environment where individuals are supported and recognized for their work and achievements. They feel inspired and empowered to innovate and change, resulting in positive outcomes for the organization. Theoretical models of relationship-based leadership include innovation leadership, transformational leadership, servant leadership, and authentic leadership.

Important questions to ask regarding measurement of outcomes from an EBP implementation project include the following:

Are the outcomes of high importance to the current healthcare system? • Are the outcomes of interest sensitive to change over time? • How will the outcome(s) of interest be measured (e.g., subjectively through self-report and/or objectively by observation)? • Are there existing valid and reliable instruments to measure the outcomes of interest? • Who will measure the outcomes, and will training be necessary? • What is the cost of measuring the outcomes?

Authentic leaders are able to build trust and healthier work environments through four types of behaviors, including

Balanced processing—objectively analyzes data to formulate decisions; solicits views that may challenge traditional ideas to come to a conclusion; possesses the capability for accurate self-assessment; and can act on these assessments without being diverted by self-protective intentions Internalized moral perspective—role models high standards for moral and ethical conduct Relational transparency—presents their genuine self to their followers; shares values, emotions, and goals in a transparent manner that encourages followers to be forthcoming with their ideas and opinions strives to achieve trust by listening to and accepting others' opinions and views and acting on recommendations Self-awareness—understands their own unique talents, beliefs, and desires; uses knowledge of self to enhance leadership effectiveness

strategies to address barriers to implementing and sustaining a culture of EBP

EBP education and skills building Develop EBP content and skill-building programs targeted to clinicians at various levels of practice including staff, managers, and directors Include EBP content and the EBP competencies in onboarding/orientation and residency programs designed for new hires Operational budgets for EBP resources Purchase computers dedicated for EBP work Allot/budget time for EBP project work Library services support Access to library with adequate clinical databases and journals available Support from librarians knowledgeable in EBP steps and processes Job descriptions and performance evaluation tools Write or revise job descriptions with EBP competencies/expectations articulated Write or revise performance appraisal tools with EBP outcomes/deliverables articulated Clinical ladder requirements Write or rewrite clinical ladder application with progressive EBP requirements at each level Organizational vision, mission, and values statements Write or rewrite organizational and departmental vision, mission, and values statements with EBP language integrated Engage the team in the vision and mission and keep them focused on and excited about it EBP mentors aligned within the organization Develop a cadre of EBP mentors centrally within the organization to work with point-of-care clinicians to implement EBP and to promote, support, and sustain a unified message and vision of EBP Designate a dedicated, knowledgeable EBP leader to oversee EBP mentors and activities and to help create and inspire the EBP culture EBP mentor positions Create designated EBP mentor positions with specific job descriptions Align EBP mentors centrally in the organization Hire individuals with robust knowledge and skills in the steps of EBP as well as in individual behavior and organizational change theory to fill EBP mentor positions Manager and leader accountability Write or rewrite leadership job descriptions with EBP expectations articulated Write or revise performance appraisal tools with EBP outcomes/deliverables required

Evaluating implemented EBP

Evaluating outcomes produced by clinical practice changes is important at the patient, clinician, and unit, departmental, organizational, or system level. Outcomes reflect the impact of the process changes or structural changes. important to determine whether the findings from research are similar when translated into the real-world clinical practice setting. important to measure outcomes before (i.e., baseline), shortly after (i.e., short-term follow-up), and for a reasonable length of time after (i.e., long-term follow-up) the practice change **Each of these points in time provides data on the sustainable impact of the EBP change.

10 foundational characteristics that are central to servant leadership

Listening—consistently listens intently and carefully to others Empathy—values individuals for their unique characteristics and contributions; seeks to understand and empathize with their followers Healing—helps others to solve problems and conflicts in relationships, which supports and promotes the personal growth of their followers Awareness—views situations from a holistic standpoint, which allows awareness and better understanding of issues surrounding ethics, power, and values Persuasion—effectively builds consensus among followers and relies on persuasion, rather than power by authority, to influence others and achieve organizational goals Conceptualization—sees beyond the limits of the operating business and focuses on long-term goals Foresight—learns from the past to understand the present and identify consequences of decisions for the future Stewardship—serves the needs of others; stresses the use of openness and persuasion, rather than control Commitment to the growth of people—is dedicated to the personal, professional, and spiritual growth and development of each individual Building community—develops a true community among businesses

Levels of Data Categorical and numeric data fall within four possible levels of measurement: nominal, ordinal, interval, and ratio.

Nominal Level Data Data measured at the nominal level are the least sophisticated and lowest form of measurement. Nominal measurement scales assign numbers to unique categories of data, but these numbers have no meaning other than to label a group. Scales that describe the quality of a symptom by some descriptive format are nominal. For example, a nominal measure of the quality of pain may include categories such as "throbbing," "stabbing," "continuous," "intermittent," "burning," "dull," "sharp," "aching," "stinging," or "burning" Ordinal-Level Data -Ordinal measures use categorical data as well. Numbers assigned to categories in ordinal measures enable ranking from lowest to highest so that the magnitude of the variable can be captured. However, it is important to note that although numbers are assigned to enable sorting of findings by rank, the absolute difference in each level on an ordinal scale does not possess an equal or "true" mathematical difference in the values. -Likert scales provide clinicians with ordinal-level data using selections such as "very dissatisfied," "dissatisfied," "neither dissatisfied nor satisfied," "satisfied," and "very satisfied." Clearly, each level of progression from very dissatisfied to very satisfied describes higher satisfaction, but "very satisfied" could not be described as four times more satisfied than "very dissatisfied." When developing instruments, researchers typically use four or five categories from which to rank the variable of interest on a Likert scale. Interval and Ratio-Level Data Interval measures are the next highest level of measurement and are purely derived from numeric data with equal and consistent mathematical values separating each discrete measurement point. Although ratio-level data possess this same characteristic, the difference between these two levels of measurement is that interval data do not possess an absolute zero point. The best examples of interval-level data are temperature measures derived from the Fahrenheit scale that assigns 32° instead of zero as the point where water freezes. Measures derived from a ruler and temperatures measured on the Centigrade scale are both examples of ratio-level data. Data measured at the interval and ratio levels allow virtually all types of algebraic transformations, and therefore, the greatest number of statistical options can be applied

Incremental Testing to Determine Impact and Next Improvement Steps

Once the team's mission is clear and a baseline performance point has been established, the testing phase can begin When limited external evidence exists to support a practice change, the cycle can focus on small, incremental changes using a "let's see what happens" approach. select pieces of a new process are added slowly over time so as not to overwhelm clinicians. By recognizing data that you may never have access to, you are also able to acknowledge the limitations of your findings, which is key to your preparation and presentation of results. Gathering meaningful data in an efficient manner takes forethought, ingenuity, and familiarity with how data are best collected and the importance of measurement

Using EBP in Practice the QSEN competencies focus on the following practice areas:

Patient-centered care Teamwork and collaboration EBP Quality improvement Safety Informatics QSEN defines competency for EBP as the integration of best current evidence with clinical expertise, family preferences, and values for delivery of optimal care

Leadership strategies to implement EBP

evidence-based leadership is a problem-solving approach to leading and influencing organizations or groups to achieve a common goal that integrates the conscientious use of best evidence with leadership expertise and stakeholders' preferences and values. --Evidence-based leadership requires two levels of commitment: (1) self-actualization of EBP and public demonstration of EBP as the foundation of daily practice and decision making (2) facilitation of the enculturation of EBP throughout the organization(s) --Evidence-based leaders must be grounded in and embrace the EBP process for decision making in their practice and across the organization as well. This requires knowledge and application of key aspects of the EBP process to leadership decisions, including: =clinical inquiry and formulating PICOT questions =effective searching for best evidence =critical appraisal of evidence =evaluation and synthesis of evidence/integration of evidence into decision making/implementing =evidence-based changes =measuring and sustaining outcomes =disseminating findings

shared mental framework

exemplifies an institution's most closely held values and ideals that inspire and motivate administrators, researchers, and clinicians to participate in practice changes. It serves as the catalyst for change within the organization

Dashboards

graphic displays of information that are often used at the unit level to compare performance indicators for the population being cared for on that unit. As with scorecards, color-coding enables clear displays of performance indicators of excellence and deficiencies. Dashboards can help healthcare providers see the direct impact on performance from the care they provided

Sources of Internal Evidence Administration

may provide data related to patient complaints about care and services. Such data may be in the form of a call log or table containing information about the source, type, location, and resolution of complaints. Administrative outcomes may include data on patients' perspectives on hospital care collected through mandated surveys such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

Using EBP in the academic setting

the following should be the goals for the teaching and learning of EBP: -Increase knowledge of EBP. -Build the language of EBP (e.g., "evidence-based practice," not "evidence-based research"), critically appraising the literature (EBP) versus analyzing studies (research). -Develop EBP skills. -Create positive beliefs and attitudes about EBP. -Generate early consistent engagement in EBP.