Discussion: strategies for implementation of evidenced-based practice change

Discussion: strategies for implementation of evidenced-based practice change

Discussion: strategies for implementation of evidenced-based practice change


  • Describe the role of nurse leaders in promoting evidenced based practice.
  • Describe strategies for implementation of evidenced-based practice change.
  • Describe the forces behind a changing health care culture including current issues and trends.
  • Compare nursing work group culture with other organizational cultures. Discussion: strategies for implementation of evidenced-based practice change

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  • Initial Post: Minimum of two (2) total references: one (1) from required course materials and one (1) from peer-reviewed references.

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  • Initial Post: Minimum 200 words excluding references (approximately one (1) page). strategies for implementation of evidenced-based practice change


Leadership and Nursing Care Management, Elsevier-Saunders, 2013, 5th edition

    • Read Chapters 3,13,14,15,16.


Discussion: strategies for implementation of evidenced-based practice change. JONA Volume 43, Number 10, pp 509-516 Copyright B 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION Using a Shared Governance Structure to Evaluate the Implementation of a New Model of Care The Shared Experience of a Performance Improvement Committee Mary Myers, MSN, RN, PCCN Debra Parchen, BSN, RN, OCN Marilla Geraci, MSN, RN, PMH/CNS Roger Brenholtz, MSN, RN Denise Knisely-Carrigan, BSN, RN Clare Hastings, PhD, RN, FAAN Sustaining change in the behaviors and habits of experienced practicing nurses can be frustrating and daunting, even when changes are based on evidence. Partnering with an active shared governance structure to communicate change and elicit feedback is an established method to foster partnership, equity, accountability, and ownership. Few recent exemplars in the literature link shared governance, change management, and evidence-based practice to transitions in care models. This article describes an innovative staff-driven approach used by nurses in a shared governance performance improvement committee to use evidence-based practice in determining the best methods to evaluate the implementation of a new model of care. programs of the 27 NIH institutes and centers. In 2007, nursing at the CC launched a national effort, in collaboration with colleagues across the country, to define and describe the emerging practice specialty of clinical research nursing (CRN). This practice development agenda became the strategic focus for the nursing organization as nurses with substantial experience in clinical research as well as those new to the practice specialty began the rewarding process of uncovering, documenting, and standardizing the elements that make their practice unique. The cornerstone of CRN is the provision and coordination of nursing care for participants in clinical research studies.1 A strategic plan and team structure engaging all leadership in nursing and nursing shared governance (SG), called Clinical Research Nursing 2010 (CRN2010), were established, and groups worked for 4 years to create and validate concept documents, communicate through nursing management and advanced practice nursing structures, and discuss them with staff SG leaders.2 Nursing leadership then turned from the application of the specialty of CRN to the process of planning, delivering, coordinating, and evaluating care provided to research participants in the CC. After discussions involving all areas of practice, a recommitment was made by leadership and staff to the principles and accountability embodied in the concept of primary nursing.3 Four roles at the clinical unit level were defined: primary clinical research nurse (PCRN) (accountable for planning, providing, and coordinating care for an individual research participant), A The National Institutes of Health (NIH) Clinical Center (CC) is a 240-bed research hospital and ambulatory care center supporting the clinical research Author Affiliations: Educator, Medical Surgical Specialties (Ms Myers), Senior Clinical Research Nurse (Ms Geraci), Senior Clinical Research Nurse (Mr Brenholtz), Clinical Research Nurse (Ms Knisely-Carrigan), Nurse Consultant (Ms Parchen), Chief Nurse Officer (Dr Hastings), National Institutes of Health, Clinical Center, Nursing and Patient Care Services, Bethesda, Maryland. The authors declare no conflicts of interest. strategies for implementation of evidenced-based practice change
Discussion: strategies for implementation of evidenced-based practice change. Correspondence: Ms Myers, National Institutes of Health Clinical Center, 9000 Rockville Pike, Bldg 10 Room 5-5441, Bethesda, MD 20892 (mmyers@cc.nih.gov). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com). DOI: 10.1097/NNA.0b013e3182a3e7ff JONA Vol. 43, No. 10 October 2013 509 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. protocol coordinator (PC) (accountable for the implementation of a clinical study in a particular area and coordination of the medical and protocol-driven requirements of a group of research participants), assigned clinical research nurse (the nurse caring for the participant other than the PCRN), and the clinical research technician (Table 1).4 Standards of care were outlined to serve as a guide to the CRN detailing the ethical, compassionate, collaborative, and informed care delivered to each research participant (Table 2). SG and Evidence-Based Practice at the NIH CC Nursing SG, implemented in 1992, has undergone several updates and revisions, based on internal staff input, benchmarking with colleagues in academic medical centers and periodic review of new evidence. The SG structure includes the nursing practice council (NPC), with representatives from each nursing unit, and each nursing role in the department (eg, managers, clinical specialists, etc), as well as nurses Table 1. Roles in the Care Delivery Model Scope of Activity Primary CRN Role Assigned CRN Role Clinical Research Tech Role Focus of work Group of participants on a given protocol Individual participant who requires continuity for care spanning 91 d or visit Individual participant Individual participant or unit tasks (ie, setting up research bloods) Time frame Duration of protocol or long-term program of care Episode of care (inpatient admission or Q1 protocol related visits) Shift Shift Assessment Overall impact of protocol, level of nursing care required, clinical needs of patient population (group assessment) Health status, needs, and responses over an episode of careVpresenting and as they evolve during participation (individual assessment) Immediate presenting Immediate needs and needs, follow-up based responses to care; on prior caregiver participant initiated report, new or requests or concerns emerging needs based on changes in therapy or health status Planning Plan and standards for specific protocol-based care and patient population-based care that become part of the protocol implementation plan General and specific goals and plan for episode of care (to be achieved by the end of the episode) Priorities for care during shift, including delegation of appropriate activities. Review of existing plan; recommendations for changes based on shift-to-shift observations Implementation Education of staff; preparation of protocol-specific forms and research participant educational materials; ongoing participation in research team coordination of care Implementation of nursing plan of care, medical orders, and protocol procedures, incorporating participant feedback and adjusting as indicated by participant response Implementation of Implementation of nursing plan of care, delegated care per plan medical orders, and of care and protocol protocol procedures Evaluation 510 Protocol Coordinator Role Quality monitoring to Assessment of patient assess consistency responses over entire in implementation; episode, movement assessment of patient toward identified feedback and need for goals and change as protocol effectiveness of progresses; evaluation protocol procedures of participant outcomes with feedback to assessing for trends clinical research team and needs for and modification of changes in protocol plan as appropriate implementation plan Assessment of patient responses during shift with feedback to clinical team and recommendations for changes as appropriate Priorities for care during shift Monitoring of specific patient responses and reporting g to covering CRN JONA Vol. 43, No. 10 October 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. strategies for implementation of evidenced-based practice change
Discussion: strategies for implementation of evidenced-based practice change. Table 2. Standards of Care Clinical Research Nursing Standards of Carea 1. Research participants can expect that information about their care and condition is discussed and communicated with confidentiality and that care is being appropriately documented. 2. Research participants can expect that nurses will communicate and collaborate effectively with members of the clinical research team to ensure coordinated, high-quality care. 3. Research participants can expect that their care and treatment are consistent with the research protocol guiding their participation and that valid data are being collected by the nursing staff. 4. Research participants can expect to receive evidence-based nursing care consistent with the accepted professional standard related to their particular condition or therapy. 5. Research participants can expect to know which nurse is accountable for their care and how to contact that person. 6. Research participants can expect prompt assessment and appropriate response to changes in condition or untoward responses to research procedures. 7. Research participants can expect that treatment and monitoring will be individualized to accommodate individual needs, to the extent allowed by the protocol, and that in all cases participant safety, comfort and well-being will be placed above research requirements. 8. Research participants can expect to develop an understanding of their condition, research participation& and treatment and be able to manage self-care as appropriate after discharge 9. Research participants can expect that while in the CC, they will have a sense of being cared for as an individual and that they will receive prompt, courteous, and individualized services from nurses and patient care staff. 10. Research participants can expect to be involved with discussions and decisions about their plan of care and research participation. a CRN 2010 Model of Care.4 from other departments including perioperative medicine or interventional radiology who do not report through nursing. The chief nurse officer (CNO) is an ex-officio member. The NPC operates through subcommittees representing the areas of practice identified as important for staff representation. These include the clinical practice committee (CPC), the performance improvement committee (PIC), and the nursing information systems committee (NIS). Recently, the committee structure was expanded to include the nursing research participant education committee and the recognition and retention committee. All SG committees have representation from each clinical area and are led by a chair and cochair elected from the staff. SG works under the guidance of bylaws that are reviewed and revised each year by the NPC and administratively approved by the CNO. Each committee has a senior executive sponsor who ensures resources are provided for committee, provides policy input for the committee’s work, and provides mentorship and support to the chair and cochair. A cornerstone of SG at the CC is the nursing practice council request (NCPR), a communication initiated by a nurse and forwarded to the chair of NPC. Requests are brought forward for discussion at monthly NPC meetings; the nurse initiating the NCPR presents to colleagues and answers questions. The NCPR is assigned to an SG committee. The Figure outlines progress of a staff nurse NCPR from inception and presentation to NPC, subsequent review by the appropriate committee, return to the NPC for final vote, and implementation of practice change. As noted in the Figure, the SG structure is fluid; as prac- JONA Vol. 43, No. 10 October 2013 tice changes occur, the plan, do, study, act (PDSA)5 cycle continues the evaluative process sustaining transformation and guiding future practice changes. In 2003, nursing at the CC embraced the concept of using systematic review and evaluation of evidence Figure 1. NIH CC SG workflow and communication. a Deming.5 SG structure provides the best method to implement change and foster an environment conducive to professional growth, encouraging staff involvement from 5 inception through improved practice. The ensuing PDSA is necessary to influence sustained change and continual practice growth and development.strategies for implementation of evidenced-based practice change
Discussion: strategies for implementation of evidenced-based practice change. 511 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. to inform practice standards and practice changes.6 Evidence-based practice (EBP) was introduced to SG by engaging the CPC in the process of reviewing and evaluating evidence when considering changes to practice documents such as nursing procedures or standards of practice. Committee members were taught strategies for searching the literature, collecting and assessing evidence, and summarizing findings in a table of evidence. Nurses were supported and encouraged in making informed decisions that include assessment of feasibility in the practice environment as well as consideration of interdisciplinary colleague acceptance and current practice. EBP is now fully embedded in the nursing organizational culture and structure and is an accepted step in considering practice changes (Table 3). Using Evidence to Find Best Practices for Program Evaluation When nursing leaders at the CC developed a plan to implement a new model of care (MOC), the incorporation of staff nurse participation through SG was a natural strategy. Partnership with staff leaders and SG provided a well-documented best practice to implement change and foster an environment conducive to professional growth.7-14 Adhering to the process outlined in the Figure, the CNO used the standard NCPR asking NPC to create a plan to support the implementation. Each branch of the SG had a specified charge; CPC was asked to validate the model as feasible for implementation in each of the clinical practice areas represented in SG; NIS was asked to propose requirements for clinical documentation to support the change, and PIC was challenged to develop a strategic plan to evaluate the implementation of the MOC. EBP was utilized to evaluate best methods for initial and ongoing evaluation as well as those to assess long-term outcomes. The approach involved the same steps used to consider the evidence in support of a clinical practice change15 (Table 3) and was applied to consideration of existing evidence for the best way to evaluate an organizational change in the model of nursing care. Table 3. CC Nursing Competency: EBP 5 Steps of EBP 1. 2. 3. 4. 5. Ask the PICOa question. Access the best evidence. Appraise and analyze the evidence. Apply the evidenceVmake a practice change. Analyze and adjustVongoing evaluation after change. a P = population or problem, I = intervention, C = comparison, O = outcome. 512 Finding the Evidence A search of the literature was conducted by nurses on the PIC subcommittee to review methods utilized by organizations to assess and capture change relating to implementing models of care, including primary nursing. The question guiding the search was: ‘‘What are the best methods to evaluate the implementation of a new MOC within a hospital nursing environment?’’ The search included the following electronic databases: Health and Psychosocial Instruments, PubMed, CINAHL, Web of Science, and Scopus. Subcommittee members organized the literature review into a table of evidence including citation, level/type of evidence, strengths/limitations, and analysis/synthesis (see Table, Supplemental Digital Content 1, http://links.lww.com/ JONA/A247). Themes From the Evidence Themes included the importance of identification and consideration of primary stakeholders, the need for education of stakeholders (preimplementation through postimplementation), and the timing of evaluation (baseline, immediately postimplementation, and ongoing). strategies for implementation of evidenced-based practice change
Discussion: strategies for implementation of evidenced-based practice change. Stakeholders affected by a change in MOC include patients, nursing staff, and the physicians.16 Undergoing a transitional change in MOC has a significant impact on the primary stakeholders and the organization, and the method of evaluation should target outcomes that affect each stakeholder.17 Education was identified as integral to successful implementation and sustained practice change.16,18,19 Timing was identified as an important theme for evaluation. A unit may most effectively capture progress and growth in implementing the model by introducing the change and conducting repeated assessments.16 Spect et al20 recommended using multiple assessments over time, as well as training all staff in methods of assessment and data collection. Assessing the Impact on Key Stakeholders Impact on Patients Multiple strategies to evaluate patient perceptions of care delivery changes were identified during the review. Evaluators may create and pilot surveys21 or modify surveys previously used and adapted for their specific needs.20 Measures such as Likert scales, which collect data using graduated responses, are more sensitive and therefore more useful for demonstrating change.22 Rapkin et al22 developed structured interviews evaluating patient satisfaction using a Likert scale to evaluate 9 areas of care to assess aspects of patient healthcare experiences. Robinson et al23 JONA Vol. 43, No. 10 October 2013 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. discussed patient satisfaction indicators: respect, courtesy, competency, efficiency, patient involvement in decision making, time for care, availability, and access. Cropley24 utilized a structured survey to perform a retrospective study evaluating the effect of relationship-based care on patient satisfaction, length of stay, and readmission rates. Tonges and Ray25 utilized a structured survey to examine overall satisfaction, satisfaction with nurse, concern for privacy, pain control, response to calls, presence of a hospital-acquired infection, and outcomes influencing patient satisfaction. Seek and Hogel26 used case presentations to identify qualities of nursing care such as knowledge of system and patient advocacy, which positively impacted patient satisfaction. Shebini et al27 found that ‘‘knowing the nurse caring for you’’ improves patient satisfaction. Carabetta et al18 found that primary nursing improved patient satisfaction and that the patient felt cared for. Fernandez et al17 reported that evaluating outcomes for patients contributed to overall patient satisfaction including medication errors, adverse intravenous outcomes, pain scores, quality of patient care, pressure areas, infection rates, length of stay, readmission, and quality of care. One study demonstrated a reduced length of stay was related to the addition of a case manager role.28 In summary, the effect of changes in the care delivery model on the patient experience and patient outcomes has been a priority for evaluation but has been evaluated using multiple indicators. An assessment of a best practice MOC should therefore incorporate assessment of how the change affects patient level outcomes. Impact on Nurses Improved nurse satisfaction was identified as an important indicator of success when evaluating the impact of MOC changes.20,21,29-31 When assessing nursing satisfaction, qualitative indicators such as narratives,19 and open-ended interviews,20 researchers were able to describe meaningful changes from the perspective of nursing staff. Fernandez et al17 reported indicators identified to evaluate nurse satisfaction including interprofessional communication, professional development, support from senior staff, role clarity/confusion, nurse documentation, job satisfaction, nurse absenteeism, and nurse attrition. Winsett and Hauck32 conducted a survey asking ‘‘what does nursing mean to you?’’ and monitored nurse turnover to assess nurse satisfaction with relationship-based care. Benner33 suggests case studies and exemplars as a reliable method for teaching, relating satisfaction, critiquing one’s work, and sharing knowledge. When discussing outcomes management, Kinnaird and Dingman34 reported that nurses report high JONA Vol. 43, No. 10 October 2013 sati …

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