Evidence-Based Practice (EBP) in Nursing

Key Terms evidence. What is the best practice, or what is the best way to do this? Some of our standard practices correlational study a study examining the relationship between or among two or more variables in a are “sacred cows,” meaning they represent the way it has always been done. For instance, does every single group; it does not examine cause and effect patient admitted to your unit need their temperature taken at 7 a.m.? Perhaps not, but that is just the descriptive study used to identify and describe variables and examine relationships that exist in a way we do it, or perhaps that was the “best practice” when the policy was implemented. But what does situation; provides an accurate portrayal of the phenomenon of interest the evidence (scientific data) tell us today? As nurses, we should remain current within our practice evidence-based practice conscientious use of current best practice or research evidence in making area because the evidence is always changing and growing. Estabrooks (1998) and Pravikoff, Tanner, clinical decisions and Pierce (2005) found that knowledge sources most frequently used by nurses were school nonrandomized clinical trial same as a randomized clinical trial, but patient placement in treatment or experiences and colleague experience. Assuming this is the case, a nurse with 15 years of experience nontreatment group depends on study variables, with not every individual having an opportunity for may be using “evidence” that is 15 years out of date, and this experienced nurse who is mentoring new selection nurses may be fostering practice that is 15 years out of date. A colleague of this author once said that observational study use of structured and unstructured observations to measure study variables “health care was a long history of tradition unimpeded by progress”—the move to EBP is changing this. randomized clinical trial effects of an intervention are examined by comparing the treatment group with Examples of Some Traditional Practices not Supported by Evidence the nontreatment group; patients are placed in treatment or nontreatment group through random Use of Oxygen in Patients with Chronic Obstructive Pulmonary Disease sampling The use of oxygen at levels that potentially may eliminate “hypoxic drive” in patients with chronic research generation of new knowledge through the rigorous study of variables obstructive pulmonary disease (COPD) has long been a clinical concern (Makic, Martin, Burns, research use findings from a single study or a set of studies for the development of patient care Philbrick, & Rauen, 2013). Statements such as “if you give oxygen, you will wipe out their drive to Treatment Myths and Truths breathe and their carbon dioxide will increase,” and “it is OK for the COPD patient to have a high PaCO2 Two sentinel publications by the Institute of Medicine (IOM), To Err Is Human and Crossing the Quality and a low PaO2, they live there” are often repeated in clinical practice settings, in academic Chasm (Institute of Medicine [IOM], 2000, 2001), drew attention to quality issues in U.S. health care. A classrooms, and even in textbooks (Table 18.1). major theme of both reports is that although the technology of health care has advanced at lightning Table 18.1 speed, the delivery system has not advanced, causing potentially lethal situations in health care. One Debunking “Hypoxic Drive” and Support for Providing Oxygen to Patients With Chronic Obstructive of the most common situations seen is the increased rate of hospital-acquired infections, and one of Pulmonary Disease (COPD) the proposed solutions to the improvement of care is the use of evidence-based decision making in Evidence-Based Literature (Author, year) health care. Provide Oxygen for Acute on Chronic Respiratory Failure Provide Oxygen for Chronic Respiratory Failure Main Points The vision for the future of nursing in The Future of Nursing report (Institute of Medicine IOM, 2011) Rudolf, Banks, & Semple,38 1977 NA NA Hypercapnia during oxygen therapy in acute focuses on the convergence of knowledge, quality, and new functions in nursing. The recommendation exacerbations of chronic respiratory failure not due to “hypoxic drive” but other mechanisms that nurses lead interprofessional teams to improve delivery systems and care brings to the fore the Easton, Slykerman, & Anthonisen,36 1986 necessity for new competencies, beyond evidence-based practice, that are requisite as nurses patients in acute respiratory failure who are given oxygen; PaCO2 subsequently increases transform health care. These competencies focus on using knowledge in clinical decision making and Crossley, McGuire, Barrow, & Houston,40 1997 producing research evidence on interventions that promote uptake and use by individual providers and to high fractions of inspired oxygen after a period of rest on mechanical ventilation; provision of oxygen groups of providers (Stevens, 2013). did not result in hypercarbia or respiratory muscle failure Evidence-based practice (EBP) requires a shift from the traditional paradigm of clinical practice Dick, Liu, Sassoon, Berry, & Mahutte,35 1997 grounded in pathophysiology and clinical experience to one of the integration of best practice and in ventilation and ventilatory drive in COPD; was not due to “hypoxic drive”; although hypoxic drive is a scientific evidence. This paradigm shift allows for the continuous improvement of practice and a real phenomenon, it is responsible for only ~10% of the total drive to breathe creation of environments that stimulate innovation. Pierson,28 2000 A recent survey of the state of EBP in nurses indicated that although nurses had positive attitudes failure and a shortened life span toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in Singapore Ministry of Health SMOH, 2006 employing it in practice (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). This will oxygen in both chronic and acute on chronic COPD prove to be a challenge if we are to meet the IOM goal of 90% of practice being informed by evidence West,34 2008 NA NA Describes Haldane effect and hypoxic vasoconstriction as mechanisms of by 2020. increased carbon dioxide with provision of oxygen in COPD As a new nurse, there will be many times that you will ask yourself the following: “Why do we do it this Global Initiative for Chronic Obstructive Lung Disease GOLD, 2009 way?” or “Is there a better way to do this?” For answers to these questions you must look to the recommendations for the use of oxygen in both chronic and acute on chronic COPD NA NA Minute ventilation may decrease in some Yes NA Described response of COPD patients NA NA Described the oxygen-induced change NA Yes Dangerous to withhold oxygen. Effects of chronic hypoxia include organ Yes Yes Evidence-based recommendations for the use of Yes Yes Evidence-based ourselves the following questions and not blindly accept standard practice (Salmon, 2007): • Why are we doing it this way? • Is there a better way to do this? NA, Not applicable. • What is the evidence to support what we are doing? Use of Large-Bore IV Needles for Blood Administration • What practice guidelines support this practice? Administration of packed red blood cells (PRBCs) is often a life-sustaining measure for patients to • Would doing this be as effective as doing that? replace lost blood or treat symptomatic anemia (Makic et al., 2013). The size of the intravenous • What constitutes best practice? catheter traditionally was believed to influence the delivery of PRBCs; it was thought that smaller-bore Models of Evidence-Based Practice catheters (e.g., 22-gauge needle or smaller) result in slower infusion rates and cell hemolysis. The There are numerous models of EBP. These models are the following: common misperception, or sacred cow, is the belief that it is necessary to insert the largest-bore • The Iowa Model of Evidence-Based Practice to Promote Quality Care intravenous catheter possible to administer PRBCs to avoid destruction of cells through the • Johns Hopkins Nursing Evidence-Based Practice Model administration process (Table 18.2). • Stetler Model of Research Utilization Table 18.2 • ACE Star Model of Knowledge Transformation Catheter Gauge Recommendations and Blood Product Infusion Based on American Association of • ARCC Model: Advancing Research and Clinical Practice Through Close Collaboration Model Blood Banks Practice Guidelines The ACE Star Model of Knowledge Transformation is depicted as a five-point star defining the following Gauge of Intravenous Catheter 22–14 Description Acceptable for transfusion of cellular blood components in adults (catheter size may need to forms of knowledge: Point 1: Discovery, representing primary research studies; be adjusted for rate of infusion) Point 2: Evidence Summary, which is the synthesis of all available knowledge compiled into a single 24o22 harmonious statement, such as a systematic review; Acceptable for transfusion of cellular blood components in infants and toddlers (may require infusion through pump or syringe) Point 3: Translation into action, often referred to as evidence-based clinical practice guidelines, (Based on information from Roback, J.M.D., Combs, M.K., Grossman B., Hillyer, C. (2008). The AABB combining the evidential base and expertise to extend recommendations; technical manual: Chapter 21 (p. 615). Hoboken, NJ: Blackwell Publishing.) Point 4: Integration into practice is evidence-in-action, in which practice is aligned to reflect best Changing Peripheral IV Catheter Sites Every 72 to 96 Hours evidence; and The most common, minimally invasive hospital procedure performed worldwide is the insertion of Point 5: Evaluation, which is an inclusive view of the impact of EBP on patient health outcomes, peripheral IV catheters (Wu & Casella, 2013). Over 200 million peripheral IVs are inserted each satisfaction, efficacy and efficiency of care, and health policy (Stevens, 2013). year in the United States (Hadaway, 2012). Routine institutional policy requires replacement of Evidence-Based Practice peripheral IV sites every 72 to 96 hours. In a critical appraisal of the evidence, compared with routine EBP consists of five steps (Strauss, 2005): replacement, replacing PIV sites when clinically indicated resulted in no greater rates of PIV 1. Ask a searchable clinical question complications including phlebitis, infiltration, catheter-related bloodstream infections, occlusion, 2. Find the best evidence to answer the question accidental removal, infusion failure, or in-hospital mortality (Gilton, Seymour, & Baker, 2019; 3. Appraise the evidence Morrison & Holt, 2015). In addition to not being harmful, changing PIV sites only when clinically 4. Apply the evidence with clinical expertise, taking the patient’s wants/needs into consideration indicated resulted in decreased costs, reduction in resource utilization, and happier patients (Bolton, 5. Evaluate the effectiveness and efficiency of the process 2015). Question Formulation Evaluating practice and continually questioning “why” should become a norm in every nurse’s practice. The first thing you will need to do is to formulate the question. Defining and narrowing down the Decision-Making Model problem is very important. As nurses, we often decide on an intervention before we adequately define EBP is a decision-making model based on the “conscientious, explicit and judicious use of current best the problem. The first step in EBP is to identify either a problem-focused trigger or a knowledge- practice in making decisions about the care of individual or groups of patients” (Sackett, Rosenberg, focused trigger that will initiate the need for change. A problem-focused trigger could be a clinical Gray, Haynes, & Richardson, 1996). “This practice requires the integration of individual clinical problem or a risk management issue; knowledge triggers might be new research findings or a new expertise with the best available external clinical evidence from systematic research, available practice guideline (Dontje, 2007). Patient outcomes are a perfect starting point. resources, and our patient’s unique values and circumstances” (Sackett et al. 1996). This definition As nurses, we make numerous decisions when caring for our patients. As we make these decisions we requires nurses to carefully and thoroughly integrate evidence into their practice. are influenced by a number of factors (Craig & Smyth, 2002): This new paradigm of EBP requires the development of a clinical inquiry approach. Nurses must ask • Clinical expertise • Beliefs, attitudes first question in your critical appraisal of the evidence is whether or not this study is good enough to • Routine (tradition) use the findings. You will be attempting to determine whether the quality of the study is good enough • Organizational factors for you to use the results in the design of a nursing protocol. You would need to look at the research • State and federal policies design, the sample, and the sample size. Obviously, results from a study directed at children may not • Regulatory factors be appropriate in the design of a protocol addressed to adults. Also, a study with a sample size of four • Funding will not carry as much strength as will a study with a sample size of 1000. Some research designs are • Time more powerful than others. The fact that some studies are more powerful than others has given rise to • Factors related to the patient the hierarchy of evidence (Peto, 1993). The hierarchy of evidence for questions about effectiveness of • Clinical circumstances an intervention follows (Polit & Beck, 2013): • Preferences, beliefs, attitudes, and needs Level 1 Up-to-date, valid evidence needs to be integrated with these factors to maximize the likelihood of what a. Systematic review of randomized controlled trials we want to happen (the outcome). The more explicit the question, the easier it is to run searches b. Systematic review of nonrandomized trials through the multiple electronic databases available to nurses (CINAHL, MEDLINE, and Cochrane). For Level 2 example, you are interested in determining best practice for end-of-shift reports. If you enter “end-of- a. Single randomized controlled trial shift report” into the search line, you will receive 56 references. If you narrow the search to within the b. Single nonrandomized trial past 5 years, the number of references is cut to 32. A focused question makes your search strategy Level 3: Systematic review of correlational/observational studies much easier. It is helpful for any nurse working in a hospital to develop a good relationship with the Level 4: Single correlational/observational study hospital librarian, who will assist you in the gathering of research evidence (Table 18.3). Level 5: Systematic review of descriptive/qualitative/physiologic studies Table 18.3 Level 6: Single descriptive/qualitative/physiologic study Resources for Forms of Knowledge in the Star Model Level 7: Opinions of authorities, expert committees Form of Knowledge Description of Resources Fig. 18.1 shows an example of an evidence-based pyramid. Point 1: Discovery Bibliographic databases such as CINAHL—provide single research reports, in most FIG. 18.1 Example of evidence-based pyramid. cases, multiple reports. Point 2: Evidence Summary Cochrane Collaboration Database of Systematic Reviews—provides reports of rigorous systematic reviews on clinical topics. See www.cochrane.org/ There will be differences in the actual numbers associated with the varying levels of evidence Point 3: Translation into Guidelines depending on the model used. You need to become knowledgeable about the model used in your National Guidelines Clearinghouse—sponsored by the Agency for Healthcare Research and Quality (AHRQ), provides online access to evidence-based clinical institution. practice guidelines. See www.guideline.gov Critical Appraisal Point 4: Integration into Practice The next question to ask in your critical appraisal is whether or not the findings are applicable to your AHRQ health care innovations exchange—sponsored by AHRQ, provides profiles of innovations, and tools for improving care processes, including adoption guidelines setting. The patients used in a study will never be identical to yours, but there may be similarities. The and information to contact the innovator. See http://innovations.ahrq.gov/ following questions can be asked to determine applicability of the study to your practice area: Point 5: Evaluation of Process and Outcome National quality measures clearinghouse—sponsored by • Is it clear what the study is about? AHRQ, provides detailed information on quality measures and measure sets. See http:// • Is the sample/context adequately described? qualitymeasures.ahrq.gov/ • Are my patients/contexts so different that the results will not apply? (From Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. • Is the intervention available, or is the change possible in my setting? OJIN: The Online Journal of Issues in Nursing, 18(2).) • Do the benefits of the change for my patient/context outweigh the costs? Reliable Evidence • Are the patients’ values and preferences satisfied by change? Once you have focused your question, you need to select the best evidence. Just because something Part of this question will be to ask what these results mean for your patients. has been published either in print or on the Internet, it does not mean it is a valid source of evidence. Population, Intervention, Comparison Intervention, Outcome You must first determine the reliability of the source. Your librarian will assist you in this. A research A framework for formulating evidence-based questions is PICOT (population, intervention, comparison study on urinary catheters funded by the company that makes urinary catheters may not be the most intervention, outcome, time). Box 18.1 describes the focus of the population, intervention, comparison reliable source of evidence; a study supporting their catheter is in the company’s best interest. The intervention, outcome (PICO) question. Box 18.1 North Am, 13[4], 497–509; reprinted from Burns, N., & Grove, S. K. [2007]. Understanding nursing Focus of the PICOT (Population, Intervention, Comparison Intervention, Outcome, Time) Question research: Building an evidence-based practice, (p. 514). St. Louis: Saunders Elsevier.) Patient or Population Define who or what the question is about. As a summary, EBP can be used as a guide for implementing a research-based protocol. The steps in this model are to do the following: Tip: Describe a group of patients similar to yours. • Synthesize relevant research • Determine the sufficiency of the research base for use in practice Intervention • Pilot the change in practice Describe the intervention, test, or exposure that you are interested in. An intervention is a planned • Institute the change in practice course of action. An exposure is something that happens such as a fall, anxiety, exposure to house • Monitor outcomes (Chapter 18) mites, etc. Research Use EBP differs from research use. Research use is the process of using research-generated knowledge to Tip: Describe what it is that you are considering doing or what has happened to the patient. make an impact on or a change in existing practices (Burns, Grove, & Gray, 2018). EBP requires synthesizing research study findings to determine best research evidence. Research evidence is a Comparison intervention (if any) synthesis of high-quality, relevant studies to form a body of empirical knowledge for the selected area Describe the alternate intervention. of practice. The best research evidence is then integrated with clinical expertise and patient values and needs to deliver quality, cost-effective care (Sackett, Straus, Richardson, Rosenberg, & Haynes, Tip: Describe the alternative that can be compared with the intervention. 2000). Research Outcomes Research is the systematic investigation, testing, and evaluation designed to generate new knowledge Define the important outcomes, beneficial or harmful. or to contribute to generalizable knowledge (adapted from U.S. Department of Health and Human Services, 2009). There is now a focus on patient-centered outcomes research (PCOR). As evidence Tip: Define what you are hoping to achieve or avoid. mounted on standard medical metrics (mortality and morbidity), it was noted that metrics and outcomes of particular interest to patients and families (such as quality of life) were understudied. Thus TimeOver what period of time will this happen? attention is now drawn to the need to produce evidence on patient-centered outcomes from the perspective of the patient. Research is critical to the growth of any profession, and in nursing it is mandatory for the continued (Adapted from Craig, J., & Smyth, R. (2002). The evidence-based manual practice manual for improvements in patient care. The Iowa Model offers a visualization of how a clinical inquiry brought by nurses (p. 30). Edinburgh: Churchill Livingstone.) a nurse may develop into a research project. In reviewing and appraising the evidence, the nurse may find that there is little or no published information about the clinical inquiry. This will then lead to the The last step in the implementation of any change is the monitoring of outcomes. Was the EBP change development of research. Health care institutions that are centers of excellence will have successful? And are the outcomes sustained over time? infrastructures and resources available for nurses interested in pursuing research. In health care organizations, there may be many triggers that initiate the need for change. They can be A first step for any nurse interested in research is to join the nursing research committee at the data-driven, resulting from performance review data, risk management data, benchmarking data, and institution. Such research committees are part of the shared governance structures within the nursing financial data, or they can be knowledge-driven, resulting from new research findings, change in departments (see Chapter 6). A novice nurse may assist in an ongoing research project as step one regulatory guidelines and standards, or questions from practitioners. and gradually increase research responsibilities as he or she matures in professional responsibilities. As a nurse manager, your role will be in the promotion and implementation of EBP in your organization. Another important step is to continually ask those clinical questions that come to mind. This constant The algorithm of the Iowa Model of Evidence-Based Practice provides a visual representation of the spirit of clinical inquiry is what differentiates the nurse with a passion for improving care from the nurse development of EBP in a clinical facility (Fig. 18.2). who sees nursing as “just a job.” The following is the Magnet (American Nurses Credentialing Center ANCC, 2019, pp. 61–63) template FIG. 18.2 The Iowa Model of Evidence-Based Practice to promote quality care. (From Titler, M.G., et al. for the communication of research across the institution. [2001]. The Iowa Model of Evidence-Based Practice to promote quality care. Crit Care Nurs Clin of Study Overview • Title of study • Participate in nursing research. • IRB approval date and type of review (i.e., full board, exempt, expedited) • Always assume that it can be done better. • Study start date • Focus on the triple aim: delivery of effective, efficient, and patient-centered care. • Study completion date The IOM report (Institute of Medicine IOM, 2003) stated that as a core competency nurses must Research Team employ EBP, integrate best research with clinical expertise and patient values for optimum care, and • Nurses at the organization who are the principal investigators (PI), co-PI, or the site PI involved in the participate in learning and research activities to the extent feasible. conduct of the study Clinical Corner • Other key personnel on research team The Nurse’s Role in Medical Aid-in-Dying Laws Study Aims Innovation is a term that we hear constantly in all fields from health care to business to technology. But • Study purpose, what new knowledge will be generated, or both what does innovation really mean? Significance of the Literature Review (two pages maximum) Innovation Defined • Key references to support the significance Innovation can be defined as the intentional introduction and application within a role, group, or • Why the study is important to nursing organization of ideas, processes, products, or procedures new to the relevant unit of adoption, • What is currently known about the topic, if an intervention study, what evidence supports the designed to significantly benefit the individual, the group, or wider society. intervention or innovation This definition is largely accepted because it captures the most important characteristics of innovation: • Summarize the gap in current knowledge about the topic being addressed by the study a. novelty Innovation b. an application component • How the study will produce actionable information for nursing c. an intended benefit Sample Description More generally, innovation can be defined as a new method and/or practice device. It is an idea, • Type of sample (convenience, cohort, random) practice, or object that is perceived as new by an individual or other unit of adoption. • Inclusion and exclusion criteria Innovation in Nursing • Sample size It is no surprise that the founder of modern nursing, Florence Nightingale, was also an adept innovator. Location of Study (within the applicant organization) We all know that nurses are creative and get the job done no matter what. The American Nurses • Hospital unit(s), ambulatory care area Association Scope and Standards of Practice (2015) reinforced innovation as essential to nursing’s Study Procedures history and future, calling on all nurses to be leaders within the profession by working to influence • Procedures from initial screening through end of contact with subjects policies and encourage innovation. • Data collection methods Although innovation, as a concept, is not new to the nursing profession, the term “nursing innovation” Results does not seem to be universally defined. A proposed working definition of nursing innovation is nursing • Results of data analysis (description of sample characteristics and analysis for research question or professionals utilizing their acquired knowledge and skills to creatively develop new ways of working, hypotheses) drawing on technologies, systems, theories, and associated partners/stakeholders to further enhance Discussion and evaluate nursing practice. • Discussion and interpretation of the findings Innovation in Practice • Implications of the findings and recommendations to the organization Nursing innovation is a fundamental driver of progress for health care systems around the world. Summary Nurses work in a variety of settings with all types of patients, families, communities, and our As a new nurse entering the profession, it is imperative that you maintain currency within your interprofessional partners. This global perspective enables nurses to provide innovative solutions to the profession. Here are some strategies for using research evidence in your own practice: challenges and demands of health care delivery. Innovation in nursing care continues to be an • Read widely and critically: Professionally accountable nurses keep abreast of their practice by reading accelerating force seeking to balance cost containment and health care quality. It is considered a journals relating to their practice. critical component of business productivity and competitive survival. • Join a professional organization related to your specialty: Many innovations in practice and best Innovation in Nursing Leadership practices are shared through professional organizations. Navigating Innovation: Acting as Validators • Attend professional conferences and continuing education seminars. Leaders at the Helm: Acting as Influencers • Participate in evidence-based projects. Leading in Disruption: Acting as Strategic Advisors Tips to Innovation: Questions to Consider decisionmaker’s guide to adopting innovations. Retrieved from https://innovations.ahrq.gov/ 1. Does the innovation fit? qualitytools/will-it-work-here-decisionmakers-guide-adopting-innovations. • What is the innovation? American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver • Does it further our goals? Spring, MD. ANCC. • Is it compatible with our organization? American Nurses Credentialing Center. (2017). 2019 Magnet® application manual. Silver Spring, MD. 2. Should we do it here? ANCC. • What are the potential benefits? Costs? Centers for Disease Control and Prevention. (2009). Guidelines for prevention of catheter-associated • Can we build a business case? urinary tract infections. Retrieved from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti- • What are the risks? guidelines-H.pdf. 3. Can we do it here? Evidence-Based Practice • Are we ready for this change? Nearly 20 years ago, it was determined that the average time for scientific evidence to be translated • What changes will we have to make? into practice is 17 years. These observations have led to the development of translation and • Do we have the ingredients for success? implementation science, which aims to reduce delays and understand what factors facilitate the 4. How will we do it here? successful adoption and implementation of new knowledge into practice. • How will we measure the impact of the innovation? There are various EBP implementation models, frameworks, and theories that have been developed in • Can we try the innovation first? implementation science to advance EBP and expedite uptake of evidence into real-world settings. The • How will we implement the innovation? approaches were categorized as models that guide the process and steps of moving research into (AHRQ, 2011) practice, frameworks for understanding and exploring factors that influence implementation, classic TIPS for Selection of an Innovation theories explain change processes, specific implementation models, and evaluation frameworks. 1. Select a concept (interesting, relevant, important, useful) Process Models 2. Determine the aims or purpose of the analysis (to distinguish between ordinary and scientific usage Process models take an action or application approach. Example: The Iowa EBP Model was developed of the same concept, to clarify meaning of an existing concept, to develop an operational definition, to and originally implemented at the Iowa Hospitals and Clinics to serve as a guide to help nurses identify develop on operational definition, to add to existing theory, etc.) methods appropriate in the improvement of patient care. The Advancing Research and Clinical Practice 3. Identify all uses of concept (sources, all uses of the term, in all fields) through Close Collaboration developed by Melynk begins with an organizational assessment of EBP 4. Determine the definitional attitudes readiness, emphasizes EBP mentors, and promotes changing beliefs and skills about EBP. 5. Identify Determinants and Evaluation Frameworks a. A model case These frameworks emphasize specific factors or characteristics that will improve the uptake of b. Borderline cases, related cases, contrary cases, invented cases, illegitimate cases evidence into practice. They aim to improve adherence to guidelines or EBPs by leveraging enabling c. Antecedents, consequences factors and minimizing barriers. Example: The Promoting Action on Research Implementation in Health 6. Define empirical reference Services emphasizes the characteristics of the evidence, the context for the adoption of the evidence, Examples from Practice and the facilitation that promotes the EBP initiative and implementation strategies. Another example: Role of the Registered Nurse Practice The Consolidated Framework for Implementation Research addresses the gap between what research Admission nurse Sepsis bundle trails have shown to work and what actually occurs in real practice settings. Nurse navigator Cauti bundle Implementation and Classic Theories Discharge nurse VAP bundle Implementation theories were developed to advance knowledge about best strategies and processes Patient safety investigators Resource nurse Pivot nurse TCAB initiatives Hourly rounding Antibiotic stewardship for promoting evidence uptake. They build on classic (social cognitive theory, diffusion of innovation) and change theories from other fields. Example: The Transtheoretical Model (TTM), also known as Stages of Change Model, proposes that people move through a series of stages when modifying Mobilization nurse Mentorship program behavior. The stages identified are precontemplation (not ready), contemplation (getting ready), Nurse scribe preparation with plan (ready), action (moving forward), maintenance (managing and preventing drift), Leadership rounds Clinical leadership (DNP) Nurse residency program (From Agency for Healthcare Research and Quality [AHRQ]. (2011). Will it work here? A and termination (when appropriate). Implementation is a major step in the EBP process, but it is often overlooked and not fully evaluated post implementation. The sustaining of the action plans and outcomes are necessary to determine 6. When the new nurse is attending new employee orientation, he or she will be in an all-inclusive adherence to the practice change and to prevent practice drift back to less than required outcomes. orientation with other new hires. Nurses then have an orientation of nursing. At this time the nurse is (From Tucker, S. (2019). Implementation: The linchpin of evidence-based changes. Take a strategic informed of policies, protocols, and procedures and is with a preceptor on the unit. If a patient needs approach to translating research into practice. American Nurse Today, 14(3), 8–13.) insertion of a foley catheter, for example, the nurse should: NCLEX® Examination Questions A. Have the preceptor observe you doing the procedure 1. Quality issues in patient care came to the forefront when there were two sentinel publications by the B. Review the protocol for foley insertion Institute of Medicine (IOM), To Err Is Human and Crossing the Quality Chasm (Institute of Medicine C. Explain the procedure to the patient [IOM], 2000, 2001). Which of the following occurred? D. All of the above A. A shift from traditional paradigm of clinical practice and pathophysiology 7. Health care institutions that are centers of excellence will have infrastructures and resources B. A shift to best practices and scientific evidence available for nurses interested in pursuing research. One can join the nursing research committee. A C. The use of evidence-based practice only novice nurse may assist in an ongoing research project. Barriers for the new nurse would be: D. The use of research only A. Being overwhelmed in first nursing position 2. Evidence-based practice can be used as a guide for implementing a research-based protocol. The B. Being hired at an institution that is not a “Magnet” facility steps in this model are to synthesize relevant research, determine the sufficiency of the research base C. Feeling insecure for use in practice, pilot the change in practice, institute the change in practice, and monitor outcomes. D. All of the above What will the nurse need to know when implementing the process? 8. The National Patient Safety Goals: A. That change will meet resistance A. Form the basis of all process improvement activities B. That change will be easy B. Are a nationwide initiative C. That change is always welcome in the best practice as a nurse C. Are mandated by the Institute of Medicine (IOM) D. That change is the first step in the process D. Will improve patient safety 3. The vision for the future of nursing in The Future of Nursing report (Institute of Medicine IOM, 2011) 9. One model of quality is FOCUS PDCA (Plan-Do-Check-Act). The U stands for: focuses on the convergence of knowledge, quality, and new functions in nursing. The recommendation A. Understand the causes of variance in the process is that nurses: B. Underlying causes for assessment A. Lead interprofessional teams in improving delivery systems and care C. Unlikely reason for a variance B. Bring to the forefront the necessity for new competencies D. Understand the end result of the process improvement C. Use knowledge in clinical decision making and producing research evidence on interventions that 10. Nurses need to know the outcomes that directly affect their unit. Common outcomes for all units promote uptake and use by individual providers and groups of providers are: D. All of the above A. Infection rates 4. Evidence-based practice consists of five steps (Strauss, 2005): ask a searchable clinical question, B. Patient satisfaction find the best evidence to answer the question, appraise the evidence, apply the evidence with clinical C. Performance on The Joint Commission Core Measures expertise, take the patient’s wants/needs into consideration, evaluate the effectiveness and efficiency D. All of the above of the process. Although each step is important, which step is key? 11. Two of the common vendor satisfaction measures are: A. Ask a searchable clinical question A. Press Ganey and Gallup B. Take the patient’s wants/needs into consideration B. Press Ganey and The Joint Commission C. Appraise the evidence C. Gallup and Occupational Safety and Health Administration (OSHA) D. Evaluate the effectiveness D. Gallup and National Institute of Occupational Safety and Health (NIOSH) 5. As a new nurse you may find resistance from “seasoned” nurses regarding patient care. If this should 12. Organizations that recognize “best practice” are: occur, what would you do? A. American Nurses Association A. Explain evidence-based practice regarding patient care B. American Nurses Credentialing Center Magnet Status B. Report the nurse to the charge nurse immediately C. Malcolm Baldrige National Quality Award C. Do it the way the “seasoned” nurse does it D. Press-Ganey Questionnaire D. Say you will do it your way and she can do it her way 13. Which of the following is not one of W. Edwards Deming’s 14-point management philosophy? A. Institute training on the job B. Cease dependence on inspection to achieve quality C. Adopt the new philosophy D. Begin the practice of awarding business on the basis of price tag 14. A goal of organizational learning is to make learning: A. The end product of all data collection B. Part of all activities within the organization C. Required of all employees in clinical positions D. Match the goals of The Joint Commission (TJC) 15. “Lean” refers to: A. The attempt to make do with the smallest amount possible B. A type of financial arrangement in which dollars are saved C. Getting rid of waste in all work processes D. The streamlining of all patient processes for cost saving 16. A root-cause analysis: A. Focuses on risk management B. Is a Six Sigma model C. Determines process variation D. Is a prospective review 17. Six Sigma is a model of quality focusing on: A. Process development B. Improving performance C. Decreasing the process variation D. Statistical analysis Answers: 1. B 2. A 3. D 4. A 5. D 6. D 7. B 8. C 9. C 10. C