Amidst constant change, evidence-based practice becomes a constant.
At Landstuhl Regional Medical Center (LRMC), Landstuhl, Germany, casualties of war, nursing workforce challenges, and adult medical-surgical issues, as well as the needs of childbearing families, experienced staff, and new nurses, summon the skills of nurse scientists and other staff members of the Center for Nursing Science and Clinical Inquiry (CNSCI). The largest American military hospital and the only Level 1 trauma service that the American College of Surgeons has designated outside the United States, LRMC (pronounced “Larm-see”) exemplifies the impact of leadership on scholarship. The center’s team of PhD-prepared nurse scientists head scholarly initiatives that include inpatient and outpatient facilities at the hospital as well as satellite clinics in the Europe Regional Medical Command throughout Belgium, Italy, and Germany.
Established to promote nursing research, evidence-based practice (EBP), and enhanced decision-making (Horoho, 2011), CNSCI has progressed in less than three years to the point where nursing scholarship is now part of the culture at LRMC. This did not happen by chance, but is the result of the determination of visionary nurse leaders to realize fully the U.S. Army Nurse Corps’ “Patient CaringTouch System
,” which provides a framework for translating evidence-based projects into excellence in clinical practice. The Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001) is used to understand and emphasize EBP in clinical decision-making. Without the leadership of LRMC’s commanding officers and nurse scientists, scholarship could not survive or thrive.
A setting for nursing science and clinical inquiry
A full-service hospital that provides primary and tertiary care to more than 218,000 U.S. military personnel and their families in Europe, Africa, and the Western Middle East, LRMC is best known for its Combat Casualty Program. Since January 2004, more than 70,000 patients injured in combat in Iraq and Afghanistan have been treated there (Lee & Sprunger, 2013). At LRMC, someone is always coming or going, and, because it’s a military hospital, that includes patients and staff.
Severely wounded troops are placed in the critical care-trauma unit, where they remain for up to 96 hours. Once stabilized, patients are transported to specialized military facilities in the United States by critical-care air transport teams (CCATs). Wounded or ill troops brought to LRMC for outpatient care may be housed in the medical transient detachment barracks for up to 14 days, unless special situations arise, because LRMC does not provide long-term care. Service members either return to their units or receive further care stateside. On occasion, LRMC also provides care to wounded or ill military personnel from other countries eligible to receive U.S. military health care. Length of stay depends on patients’ health conditions.
In an environment marked by constant transition and diversity, the need for evidence-based practice and commitment to excellent patient care is constant.
Military personnel changes occur constantly, as nurses and other staff members serve tours that may range from a few months to three years. About 20-30 percent of the nursing staff changes each year. In a civilian setting, that kind of turnover would be an issue for human resources. Amazingly, it works at LRMC. Civilian nurses, who come to the medical center for two to five years, provide the greatest stability, in terms of continuity. Nurses who are spouses of military personnel stationed in the Landstuhl region help bolster the LRMC staff and also dedicate time as American Red Cross volunteers.
Although Landstuhl Regional Medical Center is in Germany, it is an American military hospital, and all nurses, physicians, and other health care providers must be licensed in the United States. Although the U.S. Army administers LRMC, personnel from the Army, Air Force, Navy, and Marines work side by side with civilian staff in caring for patients. About 30 percent of the nursing staff is civilian.
Landstuhl Regional Medical Center provides a rich setting for nursing science and clinical inquiry. In an environment marked by constant transition and diversity, the need for evidence-based practice and commitment to excellent patient care is constant. EBP is at the core of the center’s nursing-care model (Patient CaringTouch System
) and LRMC’s outpatient delivery model (Patient Centered Medical Home
). With its robust program of education about evidence-based practice and its support of nursing scholarship in all its forms, the Center for Nursing Science and Clinical Inquiry has become a critical component of health care at Landstuhl.
Leadership makes a difference
“LRMC will be a place that supports nursing research and EBP among nurses and other disciplines,” said Col. Jeffrey Ashley, PhD, RN, then deputy commander for nursing (DCN) at LRMC in a 2011 interview with the author. (The position of deputy commander for nursing is similar to that of a nurse executive officer in a large civilian hospital.) The first nurse scientist to hold the top nursing job at LRMC, Ashley, profiled in a 2012 article
in Reflections on Nursing Leadership
(Weingarten, 2012), had a stellar research record and a vision for growing nursing scholarship at Landstuhl. Viewing his position as a unique opportunity to 1) invite nurses to value their ideas and overcome fears related to nursing scholarship, and 2) encourage research and evidence-based practice, he looked forward to the day when EBP would be accepted as part of the LRMC culture and a regular nursing activity at the center. When he transitioned later that year to senior nurse scientist at Walter Reed National Military Medical Center in Bethesda, Maryland, USA, his successor, Col. Kathy Prue-Owens, PhD, RN, continued Ashley’s mission and his support for CNSCI.
One of the architects of the U.S. Army’s “Patient CaringTouch System
,” Prue-Owens understands the necessity of nursing scholarship and clearly appreciates the importance of nurses as leaders— “facilitators and champions”—in promoting scholarship and evidence-based practice. For both Ashley and Prue-Owens, leaders must be advocates who take pride in, protect, and support resources for EBP. This advocacy, they point out, translates into inspiration for staff and excellence in nursing and patient care. Their support has thus been critical to the establishment and success of CNSCI.
Real and far-reaching
Since February 2011, when CNSCI’s first three-day EBP training program was held, the center’s influence has continued to expand, with far-reaching impact now throughout LRMC. Under the leadership of DCN Prue-Owens, CNSCI has grown from one office with two PhD-prepared nurse scientists to an entire section that now includes three nurse scientists, one clinical nurse specialist who directs the EBP program, three clinical nurse specialists who represent the intensive-care unit, medical-surgical and maternal-child health sections, a statistician, and a methods analyst (also a nurse). Visible throughout Landstuhl Regional Medical Center and readily available to answer questions, from the basic to the complex, they are expert resources and serve as catalysts for a variety of scholarly nursing activities, including EBP projects and original research. Each EBP project and research study conducted by LRMC nurses is designed to meet the unique clinical needs of LRMC, its patients, and staff. These scholarship efforts are showcased to the entire hospital through such activities as nursing grand rounds, Nurses Week posters, nursing leadership journal club, and various events.
With permission from Iowa Universities Advanced Practice Institute to use its training resources to implement EBP within LRMC, the center’s nurse scientists and CNSs assist other staff in using the Iowa model to provide a structured approach to framing questions, evaluating evidence, and guiding research into clinical practice. Serving as mentors, they provide expert guidance as team members learn to ask the right clinical question and, over time, proceed to finding research-based answers. The program’s success is evident in the number and quality of nursing projects initiated at LRMC and the excitement of nurses who have come to realize their ability to undertake an EBP project and see their initial inquiries translated into improved patient care. As CNSCI continues to develop, the clinical nurse specialists work more and more with staff to translate evidence into practice, thereby freeing the nurse scientists to focus increasingly on research.
As of December 2013, more than 18 EBP projects, all based on clinical questions raised by LRMC nurses, were either underway or completed. (See sidebar titled “Learning to ask the right question.”) Progress of EBP projects is discussed at EBP Council meetings, attended by nursing leadership that includes CNSCI staff, section-level nurse leaders, nurse-performance improvement analysts, and hospital quality-management representatives. The council was chartered in August 2012 to provide nurse executive oversight and support to the EBP program. A one-up-and-one-down approach fosters honest discussion of each project. Always asked is, “What can the EBP Council do for this project?”
Technology, including teleconferencing, allows nurse scientists to connect with nurses at LRMC’s satellite clinics in such locations as Vicenza, Italy, and Wiesbaden, Germany. Through formal interactive programs and project consultation, they have educated nurses throughout the Europe Regional Medical Command about EBP. Workshop topics include the meaning, necessity, and use of EBP; how to retrieve, review, and select literature; and how to undertake an EBP project in your own setting. The ability to communicate long distance facilitates consultation and fosters communication at a time when budgets for on-site visits have been reduced.
Email and monthly teleconferencing with expert interdisciplinary faculty members and staff volunteers from Villanova University’s College of Nursing in Pennsylvania also foster exchange of scholarly ideas. This communication enhances Villanova’s participation in the White House’s “Joining Forces” initiative to promote civilian understanding and education related to care of military veterans (White House, 2012).
EBP for new nurses
After completing their BSN programs, newly licensed U.S. Army nurses typically arrive for three-year assignments at Landstuhl Regional Medical Center in groups ranging from two to seven people. Considering that staff members from the joint services are often stationed at LRMC for as little as a few months, three years is a long time, and it enables these new Army nurses to engage in scholarly activities.
They are immediately enrolled in the U.S. Army Brigadier General Anna May Hays Clinical Nurse Transition Program (CNTP), a six-month standardized program that facilitates the transition of newly licensed nurses into professionals (Dunemn, Hopkins-Chadwick, Connally, & Bramely, 2011). Initially introduced to EBP, using the Iowa Model, during their U.S. Army Basic Officer Leader Course Nurse Track at San Antonio, Texas, these newly minted nurses complete an EBP Capstone Project while at LRMC under the guidance and mentorship of CNSCI. Upon completing the six-month orientation, they present their work at a special ceremony attended by nurse leaders and other staff members. For the balance of their first year at LRMC, they receive further encouragement and support in implementing their proposed projects.
During the first year of its existence, CNSCI was able to mentor and graduate five CNTP classes—a total of 23 nurses—with successful Capstone projects. The center’s efforts have sparked appreciation for EBP by these new nurses as a process not to be feared, but rather embraced as a better way to provide patient care. Introducing evidence-based practice at the start of a nurse’s career contributes to growing a culture of nurses fluent in EBP.
EBP for experienced staff members
Although evidence-based practice is not new, the language of EBP and the current emphasis on EBP may be different for experienced nurses whose education might not have included it. To promote EBP and help such nurses overcome reluctance to adopt it in their own practice and to help nurse leaders overcome resistance to EBP, CNSCI staff members provide a series of introduction-to-EBP classes (up to four hours long and tailored to the needs of the unit or clinic), a three-day workshop for nurse leaders, and skills-fair stations that focus on “implementing EBP in your practice.” The programs are designed to ensure critical understanding of EBP at all levels, including support from LRMC’s nurse leaders.
Toward the future
Future goals of CNSCI include establishment of an EBP internship, monthly workshops with EBP facilitators, educational meetings that focus on research topics, and continued assistance for individual and group projects. Turnover also affects staffing of CNSCI, so the orientation needs of new staff members must be anticipated, and training must be swift and thorough.
At LRMC, where casualties of war and wellness from health promotion co-exist, where turnover and transition are ways of life, and where patient acuity ranges from the very high (such as severe combat injuries) to the very low (associated, for example, with healthy childbearing), CNSCI thrives. Evidence-based practice has, indeed, become an expectation. Established in 2011 with the vision and support of nursing leadership, the Center for Nursing Science and Clinical Inquiry has had meteoric success and has provided mentoring and professional development for new and experienced nurses. Ongoing education of staff members, diverse EBP projects, and successful scholarly outcomes have, despite an ever-changing population of patients and staff, made CNSCI a model for nursing and interdisciplinary scholarship in both military and civilian settings.
In the future, the center may be one of the “constants” at Landstuhl Regional Medical Center as the massive facility undergoes major change related to withdrawal of troops from Afghanistan and decline in combat-related injuries. Quite possibly, as Landstuhl transitions to a full-service military hospital in peacetime, EBP projects will increasingly focus on health promotion, health maintenance, and health restoration related to acute and chronic illnesses. Regardless of the form the transitions take, CNSCI and EBP will be part of the culture of nursing at LRMC.
Learning to ask the right question
Nurse scientists and clinical nurse specialists at LRMC’s Center for Nursing Science and Clinical Inquiry advance evidence-based practice and improve patient care at Landstuhl Regional Medical Center by teaching nurse colleagues how to ask clinical questions that lead to research-based answers. Some examples:
DVT prophylaxis bundle: Does nursing implementation of a deep vein thrombosis (DVT) prophylaxis bundle decrease incidence of DVT in post-surgical patients?
Pain management education: Does pain management education of LRMC medical/surgical nurses improve patient pain outcomes compared to current practices?
Low-dose ketamine monitoring: In patients requiring low-dose ketamine for pain management, will implementation of a standardized administration protocol on medical/surgical floors lead to administering ketamine safety and effectively with manageable side effects and adequate pain control compared to patients currently receiving ketamine in the ICU?
RN/provider rounding: In the medical/surgical wards, will structured nurse-provider communication through rounding improve patient safety and satisfaction, as well as nursing satisfaction?
Ambulatory blood-pressure monitoring: In patients diagnosed with or being screened for hypertension, would having them perform blood-pressure checks independent of the clinic, as compared to walk-in visits for blood pressure checks, result in greater screening compliance and nursing satisfaction?
Total hip clinical practice guideline: How does standardization and continuity of care using a clinical practice guideline between the inpatient and outpatient settings aid in better patient outcomes, safety, and satisfaction?
Preoperative IV acetaminophen: For patients 18 to 60 years old classified ASA I or II (American Society of Anesthesiology) who are undergoing elective laparoscopic abdominal surgery, will preemptive administration of intravenous anesthesia (IVA) prior to surgical incision result in a 20 percent reduction in postoperative pain sores and opioid requirements, compared to those who do not receive IVA?
Closed vs. open peripheral intravenous systems: Does use of closed peripheral intravenous (PIV) systems, compared to open PIV systems, in the inpatient medical/surgical setting improve patient and staff safety as well as clinical outcomes?
SBAR transfer notes: For medical/surgical and operating room nurses, could the implementation of a standardized documentation form—the SBAR (situation, background, assessment, recommendation) transfer note—result in greater than 75 percent of ward transfers to the operating room being documented in SBAR format, compared to current documentation practice?
Disclaimer: The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.
Carol-Grace Toussie Weingarten, PhD, RN, ANEF, is associate professor, Villanova University College of Nursing, Villanova, Pennsylvania, USA.
The following people from the U.S. Army Nurse Corps contributed to this article: Col. Lori Trego, PhD, CNM, ARNP; Lt. Col. Susan Hopkinson, PhD, MN; and Lt. Col. Betty Garner, PhD, ARNP.
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