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Strategies to Implement EBP Evidence-Based Decision Making Organizational Infrastructure Quality Patient Care Marita G. Titler, PhD, RN, FAAN Senior Assistant.

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Presentation on theme: "Strategies to Implement EBP Evidence-Based Decision Making Organizational Infrastructure Quality Patient Care Marita G. Titler, PhD, RN, FAAN Senior Assistant."— Presentation transcript:

1 Strategies to Implement EBP Evidence-Based Decision Making Organizational Infrastructure Quality Patient Care Marita G. Titler, PhD, RN, FAAN Senior Assistant Director, University of Iowa Hospitals and Clinics Director, Research, Quality and Outcomes Management Department of Nursing Services and Patient Care, UIHC Director, Institute of Translational Practice, Center for Research in the Implementation of Innovative Strategies in Practice, Department of Veterans Affairs Laura Cullen, MA, RN, APN Evidence-Based Practice Coordinator Research, Quality and Outcomes Management Department of Nursing Services and Patient Care, UIHC Educational Strategies for Clinicians

2 Objectives  To overview two educational programs for staff that address promoting use of EBPs Staff nurse internship for EBP Advanced Practice Institute for EBP Others we have  Nurse Managers  Senior Leaders

3 The Evidence  Nurses at the point of care delivery are in the ideal position to ask & answer clinical questions  Need strategies that link clinicians with evidence  Several steps in the EBP process are challenging  Application oriented approach with active facilitation is necessary to learn the process Cullen & Titler, 2004; Ellis, Howard, Larson & Robertson, 2005; Estabrooks, Chong, Brigidear & Profetto-McGrath, 2005; Estrabrooks, Rutakumwa, O’Leary, Profetto-McGrath, Milner, Levers & Scott-Findlay, 2005; Fink, Thompson & Bonnes, 2005; Johnson & Mighten, 2005; Pravikoff, Tanner & Pierce, 2005; Robertson, Umble & Cervero, 2003; Schultz, Whiting, Kent, Keane & Gallant, 2004; Thomson O’Brien, Freemantle, Oxman, Wolf, Davis & Herrin, 2001; Waddell & Dunn, 2005

4 The Evidence (con’t)  Complex skills are needed for leading EBP initiatives  Leadership is essential for success  Evidence-based practice work must be resourced to succeed  Translation research is a young/growing science; use of effective strategies for implementation is not broadly understood Berwick, 2003; Greenhalgh, Robert, Bate, Macfarlane & Kyriakidou, 2005; Kirchhoff, 2004; Ravaud, Keïta, Porcher, Durand-Stocco, Desmonts & Mantz, 2004; Rogers, 2003; Schultz, Whiting, Kent, Keane & Gallant, 2004; Simon, Majumdar, Prosser, Salem-Schatz, Warner, Kleinman, Miroshnik & Soumerai, 2005; Thomson O’Brien, Oxman, Davis, Haynes, Freemantle & Harvey, 1997; Titler, Cullen & Ardery 2002; Titler & Everett, 2001; Tranmer et al, 1998; Van Mullem et al, 1999

5 Audience  Staff nurses Evidence-Based Practice Staff Nurse Internship  Nursing leaders Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice

6 Strategies to Implement EBP Evidence-Based Decision Making Organizational Infrastructure Quality Patient Care Evidence-Based Practice Staff Nurse Internship

7 Purpose  Stimulate innovative thinking about efficient and effective practices to improve patient outcomes  Use the Iowa Model of Evidence-Based Practice to Promote Quality Care  Assist staff nurses with application of the evidence- based practice process  Foster professional growth and development of staff nurse interns at UIHC

8 Course Overview  Pilot program 2001  Funding  Mass mailing of brochures  Basic eligibility criteria  Simple application  Signed contract  Competitive review process  18 month program  12 meetings/year  Facilitated work time  Staff nurse, APN, & NM teams  Administrative support  Free CEUs

9 Schedule Day 1:Understanding the Iowa Model Day 2: Application of the Iowa Model and The Translation Research Model Day 3:Synthesis of the Evidence Day 4:National Evidence-Based Practice Conference Days 5-12: Implementation & Evaluation

10 Expectations of Interns  Process Full participation in and completion of the coursework Regular meetings with the leadership team Work with appropriate committee in developing the practice protocol (e.g., Professional Nursing Practice committee)  Project Outcomes Development, implementation and evaluation of one project Dissemination of project results  Peer Influence Promote use of evidence to guide practice Promote change in the clinical area

11 List of Projects  Pet visitation  Suicide risk assessment  Sedation management  Guided imagery  Bowel sound assessment  NG placement for children  Enteral feeding  Occipital pressure ulcers  OR handscrub  Fall risk assessment  Double gloving  Family transfer from PICU  Dietary restrictions  Patient education for otological procedures  Communicating end-of life wishes

12 New Cohort 2007  Pediatric Palliative Care  Bedside Swallow Screen  Blood Pressure Monitoring  Psychiatric Advanced Directives (PADs)  Sleep Deprivation  Thermoregulation of High Risk Neonate  Perineal Dermatitis

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14 Evaluation – initial cohort  Evaluation of the course content by attendee  Critique of the program by NM, APN and staff nurse with recommendations for improvement  Completed implementation and evaluation of an evidence-based practice project, including dissemination  Performance evaluation to include participation and outcomes of the program

15 Evaluation Results: Qualitative  “I know the knowledge-based for the cutting edge information of EBP”  “The opportunity for professional growth has been provided”  “Recognition that the STN observes situations/topics which need to be changed and receiving support to do this”  “I think integrating this into nursing will be a huge plus, not only for UIHC but nursing.”  “It has given me a huge self-esteem boost and I hope this internship continues for more and more nurses.” --Intern feedback, June 2001

16 Focus Group Feedback – Initial cohort Staff Nurses  Motivated by change  Partnership was critical  Time  Opportunity for growth  Coordination  Class content revisions  Mentorship Nurse Managers  Time  Coordination  Mentorship  Dissemination of results  Application process APNs  Time  Partnership for resourcing  Coordination  Growth opportunity  Program revisions

17 Final Evaluation *n = 16; combined data Strongly Disagree Strongly Agree

18 Interns’ Additional Comments  “This program is a wonderful opportunity for STNs to make a difference” -- Intern feedback, February 2002  “I have had the idea for the project for a long time. I didn’t know how to proceed or how to get the support I needed. The internship provided both for me”. -- Intern feedback, May 2003  “I feel that I will get more out of this then I could ever put into it”!! -- Intern feedback, May 2003  “I think the more skilled the mentor in EBP, the more productive the project becomes.” -- Intern feedback, February 2006

19 Keys to Success  Topic selection by STN’s  Competitive review of applications  Paid release time from clinical responsibility  Summer and holiday schedule  Regularly scheduled work sessions  Matching clinical, systems and EBP expertise  Beginning work sessions with a project update, troubleshooting & team building

20 Project Integration  Sustaining the projects is a priority (STN feedback; NM focus group feedback, February 2002)  Process involves: Reporting results to the Nursing Research Committee Development of QI goal and monitoring Development of education (orientation, competency review, temporary staff, etc.) Revisions in documentation to support practices Reporting results to Nursing QM Committee

21 Staff Nurse Recognition Celebrate Success

22 Awards  Sigma Theta Tau International EBP Award  UIHC People’s Choice Award  AORN Poster Award  Colleen Goode EBP Poster Award  UIHC Recognition Day Poster Award

23 Summary  Empowering for STN’s Staff felt valued & gained confidence Recognition for a job-well-done  Networking across department and multidisciplinary  Evaluations led to program revisions  Support from APN/NM mentors & research office is critical  Positive impact on outcomes

24 Strategies to Implement EBP Evidence-Based Decision Making Organizational Infrastructure Quality Patient Care Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice

25 Goals and Purpose  To promote advanced skills of nursing leaders in use of evidence-based practice models.  To develop leadership skills for facilitating completion of clinically relevant evidence-based practice projects.  To foster networks for creative thinking and issue resolution in the evidence-based practice process.  The purpose of the Institute is to educate nursing leaders to guide colleagues and staff in the integration of evidence-based knowledge into practice.

26 Objectives  Identify strategies for implementing and sustaining evidence-based practice changes in complex health care systems.  Describe the organizational infrastructure necessary for evidence-based practice.  Utilize the toolkit provided to promote evidence- based practice.  Train other nurses in the evidence-based practice process.  Develop a specific evidence-based practice clinical topic.

27 Overview  Three day intense workshop  Prerequisite preparation and homework  Limited group size  Small group and individual consultations  Application oriented  Emphasis on most challenging steps

28 Prerequisites  Overview of Iowa Model Readings Web-based CE course  Addressing challenges in EBP Readings  Critique research articles

29 Schedule  Day 1: Topics and teams Locating, critiquing and synthesizing the evidence Building an implementation plan  Day 2: Implementation and Evaluation  Day 3: Sustaining change Roles and project exemplars Building the infrastructure and program

30 Expectations and Resources  Apply information shared and project developed during Institute  Complete an EBP project  Develop leadership skills for facilitating EBP within their organization  Receive Toolkit and extensive resources for their project and EBP process  Consultation on-site and after the program

31 Evaluation

32 Evaluation

33 Additional Comments  “This was the best workshop I’ve ever attended.”  “I was in awe of the level of expertise and education of the faculty. It was very impressive to see what you have accomplished.”  “Immersion into the ‘world’ of EBP, the tremendous overview and detail gave me what I need to support my organization as it evolves in this excellent method of care delivery.”  “This was an awesome experience-really feel I can proceed with my project now and succeed.” -2005

34 Additional Comments  “The energy in the room was great both with the participants and instructors-as well as the staff nurses who presented. It was great to have people enthusiastic about improving patient care. I found this so refreshing because nurses historically put down other nurses and frequently stagnate other nurses. This was the complete opposite-nurse helping nurses-what a novel idea. All nurses should take this course-period! Administrative and clinical.”  “This was the best group I have been involved with in a long time. The expertise and sharing was fabulous.” -2006

35 Keys to Success  Small group of participants  Application oriented  Emphasis on implementation and other most challenging steps  Networking opportunity  Extensive number of useful resources  Project focused consultation and work time  Large group of expert faculty and consultants

36 Long-Term Program Evaluation  Questionnaire: Sent January 2007 Program attendees from 10/02-3/06 at UIHC Response rate = 33/94 (35.1%)  Respondents: 2/3 attended 1-1 ½ years prior Mean 2 years since attending the Institute

37 Program Impact  Institute was helpful in addressing challenges (mean 4.1 on 1-5 scale; 85% agree or strongly agree)  Project completion: 30% completed their project 42% still working on their project 36% working on a different project  Outcomes: Patient impact (79%) Staff impact (67%) Fiscal impact (39%) Other: “I truly believe we would not have received Magnet status without the tools from Iowa to establish EBP here.”

38 Program Impact  Shared knowledge gained from the Institute (100%)  Made changes within organizational infrastructure (82%)  Developed strategies for expanding EBP within their organization (91%)  Have formal responsibility for EBP within a specific role or committee (65%)

39 Application of Program Content

40 Mastery of Advanced Skills  Data collection for project evaluation (3.72)  Planning the pilot (3.69)  Managing a team (3.69)  Developing an action plan (3.66)  Modifying practice recommendations based on pilot (3.66)  Developing an evidence-based practice policy (3.64)  Prioritizing topics (3.58) Rated on 1-4 scale; not able to completely able

41 Implications  Facilitation is essential  Educators: Develop academic and continuing education to promote skill development Evidence: locating, critique, analysis & synthesis Data interpretations: statistical process control charts Evidence promoting sustainability of EBP changes  Leadership: Develop capacity, support, expectations and commitment to the journey

42 Summary  EBP work can be challenging  Unique educational strategies are needed  Distinct programs address audience learning objectives (e.g., basic and advanced)  Programs can be successful using a learn by doing approach with sufficient facilitation  Evaluations are positive and healthcare outcomes improve

43 Is Practice Based on Evidence? TRADITION Internship: Cullen, L. & Titler, M.G. (2004). Promoting evidence- based practice: An internship for staff nurses. Worldviews on Evidence-Based Nursing,1(4), Institute: Institute: asedpractice/apinstitute.html

44 Additional Reflections  Demand is high  Nurse driven interdisciplinary improvement of care delivery  Return on investment is good  Mentorship at the organizational level ANMC St. Cloud, Minn.  Interdisciplinary program  Intensive yet fun


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