NH 396 Final Quiz Module 9-14

"Are we doing the best thing"?

EBP (Implementing) Question

Evidence-Based Practice Workshops Journal Clubs Academic-Service Partnerships

EBP teaching strategies

Partnerships EBP Workshops Journal Club

Educational Strategies for Teaching Evidence-Based Practice

"Are we doing the best thing... right, and continuously?

QI (Conducting) Question

Data obtained from multiple sources from rigorous research to anecdotal information

EBP

Stetler Model of Evidence-Based Practice Iowa Model - Evidence-Based Practice to Promote Excellence in Health Care Model for Evidence-Based Practice Change (Larrabee's Model) Advancing Research and Clinical Practice through Close Collaboration Model (ARCC Model) Promoting Action on Research Implementation in Health Services Model (PARIHS Model) Clinical Scholar Model Johns Hopkins Nursing Evidence-Based Practice Model Stevens Star Model of Knowledge Transformation

8 common EBP models

Is the following statement true or false? Evidence-based practice competencies as identified by Melnyk, Gallagher-Ford, Long, and Fineout-Overholt (2014) are basically same for both the practicing registered nurse (RN) and the advanced practice nurse (APN).

False

Which of the following is NOT a key concept in the definition of evidence-based practice? A. External evidence (research) is the primary source of evidence for decision making. B. It is a lifelong decision-making process. C. Patient preferences and values are considered. D. The goal of EBP is to improve outcomes for individuals, groups, communities, and systems.

A. External evidence is the primary source of evidence for decision making.

EBP and Innovation

Are essential to high quality healthcare

leadership in which leaders are confident, hopeful, optimistic, resilient, transparent, and possess high moral character. Core behaviors of leaders: Balanced processing Internalized moral perspective Relational transparency Self-awareness

Authentic Leadership

What leader: Presents genuine self to followers and shares their values, emotions, and goals in a transparent manner

Authentic leader

Which of the following is NOT an essential resource that supports teaching EBP in clinical organizations? A. An organizational plan to educate staff at all levels B.A large cadre of doctoral-prepared nurses C. A theoretical model to help guide organizational change D. EBP education for staff from board room to bedside

B. A large cadre of doctoral-prepared nurses

Leveraging academic-practice partnerships is a sound strategy to increase teaching of EBP in clinical settings. Which of the following is NOT an asset that might be leveraged as part of the strategy for bringing EBP education to clinical settings? A. Academic faculty with advanced knowledge of EBP B. Clinical nurse educators who have knowledge of EBP and the culture of their units/organization C. University policies and procedures around course creation D. Leadership that supports EBP integration and education

C. University policies and procedures around course creation

The challenge we face is how to use evidence to an individual patient using large sample data! * ... how to use past experience to every single patient we have * ... how to seemingly see all patients to be the same because of their presentation

Challenge W/EBP "brokering" process

Dealing with skepticism & misperceptions Knowing individual personality styles Developing strategic plan with goals Communicating the vision & plan

Challenges to EBP Implementation

Analytical & detail oriented Competent, cautious, careful & contemplative Can experience "analysis by paralysis" May prolong planning stage of new initiative so long that others lose enthusiasm Strategy: Show them details of specific action plan

Contemplators

Practice expertise Clinical/Patient values Culture of innovation Culture of care

Culture of Innovation

Lack of depth of information <20% abstracts ever published

Disadvantages of dissemination at professional meetings

Find a mentor Find a journal the publishes the kind of paper you are writing! Consider the audience Attend writing workshop Co-author publication Start small; get bigger Low impact to higher impact journals

Disseminating Evidence through Publication

Internal + external evidence Psychosocial science Basic science Methodology matters! Clinical reasoning

EBP "brokering" process

EBP necessary component of quality care Investment of resources into EBP integration Integration of EBP into practice demonstrates commitment to safe & quality of care To change health care, point-of-care clinicians to upper leadership must understand EBP Current clinicians without EBP in their educational preparation

Importance of Teaching EBP in Clinical Setting

What leader: Evaluates new technology from the perspective of enhancing the organization rather than purely "to be first"

Innovative leader

Write or revise job descriptions with EBP competencies/expectations articulated Write or revise performance appraisal tools with EBP outcomes/deliverables articulated

Job descriptions and performance evaluation tools

Vision: Greatest buy-in when vision is created & shared by the group Belief: In one's own ability to accomplish vision Strategic Plan: Roadmap with goals, implementation strategies, outcomes, and timelines Additional key elements: Agility, Action, Persistence, Patience

Key elements of organizational change

Write/revise leadership job descriptions to reflect clear EBP expectations Write/revise performance appraisal tools with required EBP outcomes/deliverables

Manager/leader accountability

Manager and leader resistance

New barriers to EBP

Purchase computers dedicated for EBP work Allot/budget time for EBP project work

Operational budgets for EBP resources

More formal Less interactive Brief Q & A period Limited interaction with colleagues Shorter Typically presentation 20 minutes or less

Oral Presentation

Patient-centered care - Providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions The Institute for Healthcare Improvement (IHI, 2013) describes "patient-centered" as placing an intentional focus on patients' cultural traditions, values and personal preferences, family issues, social circumstances, and lifestyles Examples: PCORI

Patient preferences and values

: Critiqued by team of reviewers who have expertise in subject matter

Peer-reviewed journals

Lack of time Lack of knowledge and skills Lack of resources Lack of EBP mentors

Persistent barriers to EBP

The Environmental Forces: Complexity model innovation addresses gaps between which of the following areas and innovation?

Practice expertise

Assess & eliminate barriers Prioritize clinical issues Evaluate the infrastructure Develop experts in the EBP process

Promote Engagement of EBP

Monitor evidence‐based practice change and outcomes continuously • Modify practice based on results • Generate internal evidence • Improve care

QI (Conducting) Process

QI is focused on ... generating internal evidence about process and outcomes in the setting/environment that generated it.

QI (Conducting) Purpose

"D" Personality Styles: Drivers "I" Personality Styles: Inspired "S" Personality Styles: Supported & Steady "C" Personality Styles: Contemplators

Reference: Rohm & Carey (1997) DISC model in Melnyk & Fineout-Overholt

Search the literature to determine the gap • Ask a research question or • Test a hypothesis • Generate new knowledge • Disseminate findings

Research (Utilizing) Process

Research is focused on... discovering new knowledge that can be generalized to large groups of people.

Research (Utilizing) Purpose

"What is the best thing to do"?

Research (Utilizing) Question

Which key component of a SMART goal is missing from the following case study? Hospital-associated pressure injuries have been on the rise in the Sunshine Hospital for the chronically-critically ill. A new evidence-based protocol has been implemented. The staff are tracking the number of patients with hospital-associated pressure injuries (HAPIs) to see if they can reduce the incidence of HAPIs.

Time-Bound

What leader: Doing things right rather than ensuring that others do the right things

Transfor-mational leader

Targeted intervention to enhance beliefs about EBP EBP education and repetitive skills building EBP mentorship and support A culture and an environment that supports EBP Leaders and managers knowledgeable in EBP Mutual commitment to EBP among organizational leaders at all levels Resilience and perseverance to keep the momentum going

Interventions Vital to Consistent Implementation of EBP

Engaging in personal reflection and ego management Adopting a style of appreciative inquiry Developing high levels of emotional competence Using creativity and open dialogue to make decisions as a team Continually being mindful of the bigger picture in which decisions are being made Demonstrating willingness to stretch performance

Leadership and Innovation

Access to library with adequate clinical databases and journals available Support from librarians knowledgeable in EBP steps and processes

Library Services Support

PDCA, DMAIC, Six Sigma, TQM, Lean process, dashboards and scorecards IRB for publication

QI (Conducting) Techniques/Methods

About fixing problems • Based on internal data • Process focus • Not generalizable • Limited reliability

QI/PI Process is:

Identification of manuscript's author(s) removed & anonymity of reviewers is maintained during review process

Blind Review

Changing health care provider characteristics Attitudes towards research in practice Environment & workplace Clinical education about EBP

Clinical EBP Challenges and Facilitators

Experience is not exposure to an event; not a function of time Experience is a turning around of preconceptions, expectations, sets, and routines or adding some new insights to a particular practical situation needs to occur experiential learning The concept of self-improvement From individual to organization (bottom-up or top-down approach?) All clinicians can engage in evidence-based decision making; however, the ability to embrace the ambiguity in healthcare and anticipate the complexity in a patient situation is key to demonstrating clinical expertise

Clinical Expertise

set includes knowledge, skills, and experience related to direct practice with clients and includes diagnosis, assessment, engagement, relationships, communication related to warmth and genuineness as well as knowledge of theory, and mastery of skills related to specific care models and interventions (Barlow, 2004; Lambert & Barley, 2001).

Clinical Expertise continued

Write or rewrite clinical ladder application with progressive EBP requirements at each level

Clinical ladder supports

Less formal Most essential elements More interactive Stand by poster Allows time for discussion with colleagues Longer Typically displayed for several hours

Poster Presentation

Past practices Experience Collective wisdom Standards

Practice Expertise

Like to take charge of projects Highly task oriented Strategy for working with "drivers" ─ create excitement by giving drivers opportunities to lead way by spearheading specific tasks

Drivers

• Search/appraise internal and external evidence • Implement practice change based on best evidence • Measure outcomes of practice change • Disseminate findings

EBP (Implementing) Process

EBP is focused on... implementing knowledge through practice change in a narrow population and measuring outcomes.

EBP (Implementing) Purpose

PICOT, ARCC, PARIHS, Stetler, Rosswurm & Larrabee, Iowa, Hopkins IRB for protection of data and publication

EBP (Implementing) Techniques/Models

Evidence-based practice is a lifelong problem-solving approach to clinical decision making that involves the conscientious use of the best evidence with clinical expertise (including internal evidence) and patient preferences and values to improve outcomes for individuals, groups, communities, and systems.

EBP Definition

Innovation does least well in organizations that are rigid & policy dominated. Innovation is not generated from the top of system; rather from center of system. Appraisal of metrics and measures related to impact of innovation should be constructed early in process. All innovation must create a product or generate an impact. Otherwise there is no purpose or value.

EBP Fast Facts

Establish formal implementation teams Build excitement while implementing EBP Disseminate evidence Develop clinical tools Pilot test the EBP change Preserve energy sources Allow enough time for success Celebrate success

EBP Integration

Not directional • Based on clinical inquiry • Outcomes focus • Not generalizable • Varied reliability

EBP Questions are:

Support Encouragement Role modeling Giving "voice" to clinicians Negotiating work conditions Supporting needed education and skill building Raising call to a common vision/purpose Demonstrate continuous commitment Keeping momentum going

EBP Supportive leaders are:

Develop EBP content and skill-building programs targeted at clinicians in various levels of practice including staff, managers, and directors Include EBP content and EBP competencies in orientation and residency programs designed for new hires

EBP education and skills building

- EBP essential for optimal patient outcomes & clinical educators must promote & sustain everyday implementation - Clinicians believe practice should be based on research, but often healthcare organizational leadership do not value EBP as high priority - Barriers to EBP implementation remain in clinical setting - skill level of clinician, lack of time & managerial support - Clinicians must have necessary tools to engage in EBP. Hence, teaching EBP is imperative for healthcare organizations - Teaching EBP is leadership responsibility & requires organization commitment - Tiered educational approach is needed to engage managers, educators & point-of-care clinicians

EBP fast facts

Create specific job descriptions for designated EBP mentors (include robust knowledge and skills in EBP, motivation, and change theory) Align EBP mentors centrally in the organization

EBP mentor positions

Structure EBP mentors/champions centrally within the organization to promote, support, and sustain a unified message and vision of EBP Designate a dedicated, knowledgeable EBP leader to oversee EBP activities and create and inspire the EBP culture

EBP mentors aligned within the organization

No one best model More research needed to understand advantages of one model over another Know models sufficiently well to decide what model(s) most apt to making evidence-based change in your practice

EBP model characteristics

-Best external evidence -Clinical expertise (including internal evidence; patient assessment data; availability of health care system resources; knowledge of the organizational state, setting, and circumstances) -Patient preferences and values -Broader than Research Utilization

EBP vs Research Utilization

Outcome Measures Quality Care Improvement Patient-Centered Quality Care Efficiency of Processes Environmental Changes Professional Expertise

Evaluation: Linking EBP Clinical Outcomes

1. Questions clinical practices for the purpose of improving the quality of care 2. Describes clinical problems using internal (organization- generated) evidence 3. Participates in the formulation of clinical questions using PICOT format 4. Searches for external (research) evidence to answer focused clinical questions 5. Participates in critical appraisal of pre-appraised evidence Participates in the critical appraisal of published research studies to determine their strength and applicability to clinical practice 7. Participates in the evaluation and synthesis of a body of evidence gathered to determine its strength and applicability to clinical practice 8. Collects practice data systematically as internal evidence for clinical decision making 9. Integrates evidence gathered from external and internal sources in order to plan evidence-based practice changes 10. Implements practice changes based on evidence and clinical expertise and patient preferences to improve care processes and patient outcomes 11. Evaluates outcomes of evidence-based decisions and practice changes for individuals, groups, and populations to determine best practices 12. Disseminates best practices supported by evidence to improve quality of care and patient outcomes 13. Participates in strategies to sustain an evidence-based practice culture 14. Systematically conducts an exhaustive search for external evidence to answer clinical questions 15. Critically appraises relevant pre-appraised evidence and primary studies including evaluation and synthesis 16. Integrates a body of evidence from nursing and related fields with internal evidence in making decision about patient care 17. Leads transdisciplinary teams in applying synthesized evidence to initiate clinical decisions and practice changes to improve health of individuals, groups, and populations 18. Generates internal evidence through outcomes management and EBP implementation projects for the purpose of integrating best practices 19. Measures processes and outcomes of evidence-based clinical decisions 20. Formulates evidence-based policies and procedures 21. Participates in the generation of external evidence with other healthcare professionals 22. Mentors others in evidence-based decision making and the EBP process 23. Implements strategies to sustain an EBP culture 24. Communicates best evidence to individuals, groups, colleagues, and policy makers

Evidence-Based Practice Competencies for Advanced Practicing Registered Professional Nurses

Competencies 1-13

Evidence-Based Practice Competencies for All Practicing Registered Professional Nurses

A physical therapist reads a clinical practice guideline about the benefits of yoga for individuals with low back pain and decides she would like to incorporate yoga practices into her clients' care. She shares information about yoga practices with her clients. If clients agree to add yoga to their plan of care, she asks them to complete a pre- and post-survey at the start and end of therapy to evaluate the effectiveness of this approach. She shares her findings in a poster presentation at a local symposium.

Evidence-Based Practice Example

Best evidence Leadership expertise Stakeholders' preferences and values

Evidence-based leadership is a problem-solving approach to leading and influencing organizations or groups to achieve a common goals that integrates the conscious use of:

↑ blood loss Type & cross for blood transfusion HIV emerging but donated blood not yet HIV tested To transfuse or not transfuse? Level of evidence used to make decision? Level VII - Evidence from expert opinion Decision: No transfusion

Ex 1: Baby # 1 - Cesarean section birth 1984

External cephalic version or not? Considerations: Previous C-Section & footling breech Level of evidence to make decision? Level VII - Evidence from expert opinion "I need to talk to a colleague who has more gray hair than I do." Decision: No version & repeat C-Section Current Evidence: Level V - Systematic reviews of descriptive studies Previous C-Section with transverse incision relative contraindication to external cephalic version

Ex 2: Baby #2 - Footling Breech 1987

Trail of Labor after Cesarean (TOLAC) with oxytocin? Level of evidence to make decision? Level VI: Limited # of descriptive studies Decision: TOLAC with oxytocin Outcome Fetal distress & emergency C-section "Uterine window" Current Level of evidence: Level V - Systematic reviews of descriptive studies TOLAC with oxytocin- threefold higher risk of uterine rupture than those ♀ with spontaneous labor

Ex 3: Baby #3 - 2 previous C-Sections 1993

Level of evidence to make decision? Level IV - Cohort studies Limited # of studies Increased complications with ↑ C-sections Without adequate power to determine whether maternal deaths ↑ as # of cesarean deliveries ↑ Decision: Repeat C-section

Ex 4: Baby #4 - 3 previous C-Sections 1997

: non-profit such as government, foundations; for-profit corporations, such as pharmaceutical companies; and professional organizations

External mechanisms for funding

True or False; Complexity leadership is a form of leadership that provides a structured and systematic approach to building systems where knowledge management, generation, translation, and application can occur.

False

Eligibility criteria Membership, geographical area, credentials Contact or send letter of intent Find a good match (scope, mission of agency) Look at previous successful projects Guideline from the agency Timeline and deadline

Grant Areas of Awareness

leaders who create infrastructure that weaves innovation in the DNP of their organizations. Employees are both empowered and encouraged to challenge the status quo and integrate new processes and technologies. Competencies Include: Assessment for innovation (personal awareness) Future focused Value-driven

Innovative Leaders

Socially oriented & like to have fun Inspirational, influencing, impressive & interactive Strategy: Get individual excited about new initiative

Inspired

Academic medical centers, schools within university settings, and healthcare organizations to fund small research projects (e.g., pilot and feasibility studies),

Internal mechanisms for Funding

set includes knowledge, skills, and experience related to teamwork, organizational design and development, and leadership (McCracken & Corrigan, 2004

Organizational Expertise

Write or revise organizational and departmental mission, vision, and values statements with EBP language integrated throughout

Organizational mission, vision, and values statements

Interprofessional teamwork! Organizational context Overcoming resistance Organizational culture & mentorship Preventing fatigue

Overcoming Barriers to EBP Implementation

A nurse practitioner working in an acute care setting notices a rise in the incidence of central line infections among his patients. He develops a protocol for registered nurses to use when caring for patients with central lines, educates nurses on its use, and implements the protocol. He monitors institutional data before and after implementation to determine how this affects infection rates throughout the hospital. He shares his findings in the institution's newsletter and gives a presentation on his findings to hospital staff and administrators.

Quality Improvement Example

Quantitative Research Methodologies Qualitative Research Methodologies IRB for human subjects protection

Research (Utilizing) Techniques/models

A speech-language pathologist notices that many of her patients with childhood apraxia of speech also show symptoms of learning disability and wonders if there is an association between these conditions. She decides to survey parents of children with apraxia to measure symptoms of learning disability in this population. She shares her findings in a presentation at a local conference.

Research Example

The use of research, often a singular study, in clinical decision making

Research Utilization

Directional • Based on theory • Generalizable • High reliability

Research is:

Organizational support and commitment Resistance to EBP implementation Knowledge about EBP processes

Research studies over the last two decades have found that some barriers to EBP have changed in their importance while others remain. Select all of the barriers that still have impact on building and sustaining an environment favorable to EBP:

leadership in which leaders and followers share power. Leaders focus on followers' growth and well-being to reach their full potential and performance. Foundational characteristics: listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to growth of people, and building community.

Servant Leadership

What leader: Based on the essential elements of trust, empathy, caring, and a focus on others

Servant leader

Minimum amount of info on each slide Acronyms defined Be able to read text - guideline: no less than 24 size font for major points Dark background with light lettering No more than 1 to 2 slides per minute of presentation time

Slides to Disseminate Evidence

Specific Measurable Applicable Relevant Time-bound

Smart Goal

So what is the prevalence of the problem? So what will be the end outcome of the study or project once completed? So what difference will the study or project make in improving health, education or healthcare quality, costs, and most importantly, patient, family, or community outcomes?

So What Factor

Reserved & like to be led Socially oriented & likes to be led Supportive, steady, shy Strategy: Lead the way, telling "supportive & steady" individuals their contribution to project is important But they will not be responsible for spearheading effort

Supportive & Steady

Forming: Anxiety, excitement, exploration & trust Storming: Resistance to different approaches, attitude changes, defensiveness, tension, disunity Norming: Satisfaction increases, trust develops, responsibilities shared, decisions made Performing: Interaction high, performance ↑, optimism

Team Development Stages

set includes knowledge, skills, and experience related to formulating questions, conducting a systematic electronic search, and evaluating validity and reliability of findings for use in evidence-based decision making (Gibbs, 2003).

Technical Expertise

Precontemplation Contemplation Preparation Action Maintenance

The Transtheoretical Model of Health Behavior Change

leadership in which leaders and followers discover meaning and purpose of their work through their relationships. Four dimensions of leadership: Idealized influence Inspirational motivation Intellectual stimulation Individualized consideration

Transformational Leadership

Is the following statement true or false? There are three main categories of EBP models. They are: 1. EBP, research utilization, and knowledge transformation processes 2. Strategic/Organizational change theory based models 3. Knowledge exchange and synthesis for application and inquiry

True

Example from text that demonstrate key essential elements to be successful in making organization change

Walt Disney, Robert Jarvik, Thomas Edison

Only decisions that result from thoughtfully responsible behavior External evidence does not meet being clinically meaningful. Adapts to changes External evidence that is valid, reliable, and applicable (i.e., credibility) Clinicians' understanding of the evidence (clinical wisdom). Having a belief without supportive external evidence is unjustified, leading to unjustified decision

What makes a decision justified?