Journey to evidence-based healthcare

Laura Cullen and Kirsten Hanrahan | 04/24/2018

Vision, infrastructure, climate, resources, reporting, and recognition are essential elements.

Journey to evidence-based healthcare

As clinicians look for opportunities to improve practice, they can grow EBP skills by following a road map that ensures clear understanding of the organization’s EBP process.

Laura CullenEvidence-based healthcare makes a positive difference for patients and their families; excellence in providing that care is a pressing need. Adoption of evidence-based practice (EBP) leads to important improvements in outcomes for patients and their families as well as for clinicians and organizations. Healthcare-acquired conditions and complications are reduced, patient symptoms are improved, and cost of care is less.

Building support, however, for nurse-led EBP is a journey of persistence that requires a strategic and multifaceted approach. As part of their daily work and as members of interprofessional teams, nurses can lead the way in advancing EBP. A clear vision, infrastructure, climate, resources, formal reporting, and recognition—discussed below—are essential elements of the journey.

Vision
Kirsten HanrahanThe Institute of Medicine calls for 90 percent of healthcare to be evidence-based by 2020. To move the needle in that direction, nursing leaders must communicate a clear vision for EBP within their organizations. Where do we want to be, and when can we expect to get there? To achieve this goal, a vision statement that defines the desired future state of EBP within the organization is needed.   

A vision statement should encourage the organization to stretch and grow. It might lead to, for example, creation of a climate that supports increased evidence-based inquiry via nurse-led EBP initiatives, an EBP center of excellence, or pursuit of leadership in EBP with national reach. Vision statements should be based on values that resonate with nurses, such as improving quality and safety for patients.

Infrastructure
To provide a sound foundation for evidence-based healthcare delivery, key organizational committees and departments must design a strong infrastructure, overseen by nurse executives, that gives direction, supports acquisition of expertise and resources, and provides effective reporting mechanisms. A small group of EBP experts can facilitate the work of teams, guiding them through the process and linking them to resources for innovative practice improvements based on evidence. Consider making these experts regular members of key committees.

One committee needs to maintain primary responsibility for leading and developing EBP, providing guidance for all. Operating within a shared governance structure, additional committees within the organization should have functional responsibility to support EBP and be in sync with the aims of the overall group. For example, a committee with responsibility for quality and safety should also have functional responsibility for building EBP expertise, promoting its use, and reporting on EBP initiatives. Roles and responsibilities that support evidence-based care and operational decision-making are needed across an organization. Job description and performance-appraisal elements that promote EBP go a long way toward operationalizing the work.

Climate
A well-defined vision for EBP combined with a strong and well-designed infrastructure create a supportive organizational culture that promotes a climate in each clinical area for providing evidence-based care. When an organization focuses on inquiry and safety, frontline nurses are encouraged to ask important questions, such as why, how, and what. As clinicians begin looking for opportunities to improve practice, they can grow their EBP skills by following a road map that ensures a clear understanding of the organization’s EBP process. Adopting an EBP process model is an important part of the EBP journey.

The organization’s EBP infrastructure may impact how and where nurses are encouraged to question practice. Identifying the best method for addressing a question—quality improvement (QI), research, or EBP—depends on the question posed. Questions related to efficiency, for example, are often answered more quickly through QI methods. When little evidence is available and risks are unknown, conducting research is often the best method. When evidence regarding a particular question is available, follow the EBP process, use effective implementation strategies, and monitor for unintended consequences.

A supportive EBP climate provides professional development opportunities for EBP, adopts a model for EBP, and rewards and recognizes EBP work. On the other hand, a climate in which organizational constraints, lack of reimbursement, inadequate resources, and lack of trust are the norm adversely impacts EBP. A supportive climate empowers frontline clinicians to sit in the driver’s seat and lead the way on the journey.

Organizational leaders create the climate for EBP by establishing clear expectations and consequences—both positive and negative. Including elements of EBP in every job description across the organization sets expectations for integrating EBP in daily work. Organizational leaders can then help nurses be accountable for EBP behaviors and outcomes through routine audits, feedback, and regular performance appraisals.

Resources
Clinicians are in the ideal position to identify EBP opportunities. Because a significant number of tools and resources are needed, it is essential, despite the current cost-cutting environment of healthcare and public education, to provide access to a robust library and expert medical librarian. Efficient searches with best-evidence yields occur when clinician and librarian collaborate.

Professional organizations are also a good starting point. Many offer online access to specialty-specific resources for practice, recommendations for practice, and tools. After the best evidence has been identified and synthesized within the body of evidence, a practice recommendation, created in collaboration with clinicians as well as patients and families, is needed to fit the specific situation and setting.

An EBP mentor is another valuable resource, particularly for clinicians unfamiliar with the EBP process. External facilitators can help jump-start EBP programs and build mentoring capacity, but the goal should be to turn work over to local experts. EBP experts and nurse scientists are ideally positioned to guide clinicians. Frontline clinicians with advanced EBP training and experience can be excellent mentors, as they know both the process and real-world clinical challenges.

Collaborating with both practice and academic experts may facilitate sharing and promote professional development opportunities that reflect both perspectives. To be of benefit in navigating the process, mentors need to have practical experience in EBP’s most challenging steps, which include evidence synthesis, practice change design, implementation, and evaluation. Baseline process and outcome data should guide implementation planning.

Ready-made evaluation and implementation tools can save time otherwise used for developing questionnaires and implementation strategies from scratch. To obtain useful data that consider feasibility and participant burden, expert review of evaluation tools is recommended.  Informatics leaders can provide valuable assistance by facilitating EBP evaluation and accessing data from the electronic record. Many implementation strategies can be considered, and an organized approach across EBP’s implementation phases is needed (Cullen & Adams, 2012; Liang et al., 2017; Rogers, 2003; Sharma, Pandit, & Tabassum, 2017).

Programs
To support lifelong learning, professional development and EBP training programs that meet learning needs across the career continuum are required. Nurses—from novices to experts in their specialty—can participate in and lead EBP. Building upon undergraduate nursing education, evidence-based practice programs can be designed that guide recently graduated nurses through the process of constructing simple EBP projects.

A few observations: Focusing EBP effort on unit or clinic priorities improves chances of securing leadership support and the resources needed to facilitate the work. Building on projects that have already been established also facilitates progress. Matching project work with priorities for helping new graduates transition to practice helps them operationalize their professional development and start a career of making a difference for patients.

Well-designed EBP immersion programs can provide strong support in helping point-of-care nurses lead interprofessional teams through a scholarly process that makes a positive and significant impact on patients, families, clinicians, and the organization. Essential elements of such a program include 1) description of the EBP model in use, 2) examples of successful EBP, 3) resources to facilitate steps in the process, 4) acquisition of leadership support, and 5) behind-the-scenes mentoring. Advanced programs that focus on the most challenging steps in the EBP process and help anticipate hazards and “potholes” that show up on the journey to EBP improvement are also valuable. Addressing these challenges with appropriate tools and interactive learning techniques facilitates high-level discussion and learning.

Reporting on and rewarding success
To move from adoption of a practice change to expanding and sustaining EBP across the organization, internal reporting is essential. In fact, nurse leaders have a responsibility to articulate EBP work in a way that is heard and understood by decision makers. The benefits are two-fold: 1) Senior leaders are informed about great work that has been accomplished, and 2) the business case for evidence-based care is communicated to governing boards. Communicating with boards about EBP goals, initiatives, and achievements is an important part of any successful EBP journey (Bisognano & Schummers, 2015; Institute for Healthcare Improvement, 2016; Mason, Keepnews, Holmberg, & Murray, 2013). When making these reports, include three to five brief talking points or takeaway messages, linking them to the organization’s mission, vision, values, and strategic plan.

In evaluation planning, focus on patients and families and clinical, staff, and financial outcomes that the team and organization value (Dembe, Lynch, Gugiu, & Jackson, 2014; Gardner, Gardner, & O'Connell, 2014; Institute for Healthcare Improvement, 2015; Parry et al., 2013; Stevens, 2013). Include return on investment (ROI) when possible. Cost data for calculating ROI are available from organizational sources (billing, procurement, pharmacy, or human resources, for example) as well as the literature.

Celebrate EBP successes along the way. Teams should set goals and participate in planning and recognizing achievements. Acknowledge large and small achievements. Make it fun to positively reinforce work that has been done. Managers should reward clinicians who meet or exceed EBP performance expectations while holding laggards accountable. Senior leaders should make the most of opportunities to recognize the team, showcase results, and highlight organizational success in exemplars and annual reports. 

When sharing success stories externally about your institution’s EBP program, include information about the intervention, effective implementation strategies used, and process and outcome evaluation (Dembe et al., 2014; Iowa Model Collaborative et al., 2017). Use the occasion as an opportunity to recognize and elevate the work of frontline nurses and clinical teams. If necessary, seek mentoring counsel from those who have made this journey before.

The journey continues
Are we there yet? Building and sustaining an EBP climate in a healthcare organization require a multifaceted approach from leaders at all levels. A clear vision, strong infrastructure, encouraging climate, adequate resources, timely reporting, and positive recognition are essential elements for nurse-led evidence-based practice that improves patient quality and safety outcomes. 

Creating a climate that supports evidence-based healthcare is a journey. Each element adds to progress that leads, in turn, to additional important improvements in care that positively impact patients and their families, clinicians, and the organization. RNL

Evidence-Based Practice in ActionLaura Cullen, DNP, RN, FAAN, is evidence-based practice scientist, Office of Nursing Research, Evidence-Based Practice and Quality, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, in Iowa City, Iowa, USA. Kirsten Hanrahan, DNP, ARNP, CPNP-PC, is interim director of the Office of Nursing Research, Evidence-Based Practice and Quality, at University of Iowa Hospitals and Clinics. Cullen and Hanrahan are two of six coauthors of Evidence-Based Practice in Action, published by Sigma Publishing.

References:
Bisognano, M., & Schummers, D. (2015). Governing for improved health. Hospital trustees play an important role in community health. Healthcare Executive, 30(3), 80-82.

Cullen, L., & Adams, S. L. (2012). Planning for implementation of evidence-based practice. Journal of Nursing Administration, 42(4), 222-230. doi: 10.1097/NNA.0b013e31824ccd0a

Dembe, A. E., Lynch, M. S., Gugiu, P. C., & Jackson, R. D. (2014). The translational research impact scale: Development, construct validity, and reliability testing. Evaluation and the Health Professions, 37(1), 50-70. doi: 10.1177/0163278713506112

Gardner, G., Gardner, A., & O'Connell, J. (2014). Using the Donabedian framework to examine the quality and safety of nursing service innovation. Journal of Clinical Nursing, 23(1-2), 145-155. doi: 10.1111/jocn.12146

Institute for Healthcare Improvement. (2015). Family of measure. Retrieved from http://www.ihi.org/topics/governanceleadership/pages/default.aspx

Institute for Healthcare Improvement. (2016). Governance leadership of safety and improvement. Retrieved from http://www.ihi.org/topics/governanceleadership/pages/default.aspx

Iowa Model Collaborative, Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., . . . Authored on behalf of the Iowa Model Collaborative. (2017). Iowa Model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi: 10.1111/wvn.12223

Liang, L., Bernhardsson, S., Vernooij, R. W., Armstrong, M. J., Bussieres, A., Brouwers, M. C., . . . Members of the Guidelines International Network Implementation Working Group. (2017). Use of theory to plan or evaluate guideline implementation among physicians: A scoping review. Implementation Science, 12(1), 26. doi: 10.1186/s13012-017-0557-0

Mason, D. J., Keepnews, D., Holmberg, J., & Murray, E. (2013). The representation of health professionals on governing boards of health care organizations in New York City. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 90(5), 888-901. doi: 10.1007/s11524-012-9772-9

Parry, G. J., Carson-Stevens, A., Luff, D. F., McPherson, M. E., & Goldmann, D. A. (2013). Recommendations for evaluation of health care improvement initiatives. Academic Pediatrics, 13(6 Suppl), S23-30. doi: 10.1016/j.acap.2013.04.007

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: The Free Press.

Sharma, S., Pandit, A., & Tabassum, F. (2017). Potential facilitators and barriers to adopting standard treatment guidelines in clinical practice. International Journal of Health Care Quality Assurance, 30(3), 285-298. doi: 10.1108/IJHCQA-10-2016-0148

Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next big ideas. Online Journal of Issues in Nursing, 18(2), 4.

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