Establishing a methodology for development and dissemination of nursing evidence-based practice to promote quality care.
|Author:||Pierce, Carol J.|
|Publication:||Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 U.S. Army Medical Department Center & School ISSN: 1524-0436|
|Issue:||Date: Oct-Dec, 2011|
|Topic:||Event Code: 350 Product standards, safety, & recalls|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
A component of the Army Nurse Corps Patient CaringTouch System of
Care--the Army Nursing model for standardization of nursing practice--is
the establishment of a process for the development, dissemination,
implementation, and impact assessment of evidence-based nursing practice
across our military medical treatment facilities in our worldwide
garrison and deployed settings. This article summarizes the nursing
evidence-based practice journey utilizing Army nurse scientists and a
council of nursing leaders to develop and implement Army nursing
evidence-based clinical practice guidelines (AN CPGs) within our Army
medical treatment facilities.
As with other healthcare fields, nursing practice often varies considerably with the development of institutional policies and procedures not consistently based on best-practice evidence, but rather upon personal experiences or non-peer reviewed literature accounts. Titler et al (1) defined evidence-based practice "as the conscientious and judicious use of the best evidence to guide delivery of health care services." Melnyk and Fineout-Overholt (2) identified 5 steps in the evidence-based practice process: asking the clinical questions, collecting the most relevant evidence, subjecting the evidence to critical appraisal, integrating clinical expertise, integrating patient preference and values in making a practice change, and then evaluating the practice change. While few would argue that basing nursing practice on the best evidence available is optimal, there are barriers to the actual implementation of best evidence in nursing practice, with a gap of up to 17 years from sufficient research evidence to actual change in practice. (3) The challenge for organizational nursing leaders is to establish a framework for evidence-based practice development and implementation that includes all levels of nursing, from the nurse at the patient's bedside to the director of nursing, and is embraced by the institution as an essential element in the provision of nursing care. Unfortunately, many nurses lack the background knowledge or the time to critically review literature and determine applicability to practice. (4) A positive trend is the addition of evidence-based practice curriculum to nursing academia which has resulted in a new generation of nurses who enter the healthcare organization with the ability to ask clinical questions and critique available evidence. These new nurses may actually drive the transition of practice from tradition to best practice evidence and become the change agents in healthcare organizations. The challenge for nursing leadership is to ensure that the organization is structured so that leadership establishes a supportive environment that encourages nurses to not only ask the clinical question, but to also seek the best practice answer. This requires nursing leaders to create an organizational framework that has the clinical nurse specialists and nurse scientists readily accessible and responsive to the nurses who are providing direct patient care.
The Army Nurse Corps has a long history supporting nursing research. Annually, Army Nurse Corps officers are selected for long-term doctoral health education and training followed by utilization tours as nurse scientists in the large medical centers. Currently, there are over 40 nurse scientist manpower authorizations (military and civilian) across the Army Medical Command. In addition, military nursing scientists are deployed in combat theaters of operation to support theater research programs. While nursing scientists are actively engaged in clinical research, there has been considerable variation in the utilization of nurse scientists which has detracted from the ability to integrate nursing research into clinical nursing practice. Often, the nursing research that was conducted appeared to arise from the nursing scientist's personal area of interest, with only limited application to the clinical issues and nursing care practice most impacting their assigned institution or the entire Army Medical Command. Additionally, often the research did not involve replication studies to build a body of knowledge in support of definitive practice changes, or to enhance application of the findings across diverse populations and other facilities.
Recently, through the strong direction of the Nurse Scientist Consultant to The Army Surgeon General, the nurse scientist community has established nursing research priorities aligned with the Corps' vision of implementation of nursing evidence-based practice, and reduced practice variation across our healthcare system. In order to synchronize clinical and nursing research activities, the Nurse Scientist Consultant is in the process of realigning nurse scientists, nurse clinical specialists, nurse method analysts, and nurse informatics officers into regional Centers for Nursing Science and Clinical Inquiry (CNSCI). Bridging the gap from research to bedside practice requires a coherent strategy linking the nursing scientists, advanced practice nursing clinicians, medical informatics technology support, and administrative leadership. The restructuring of the nursing research sections into regional clinical inquiry cells better supports an evidence-based practice model within each medical treatment facility (MTF), and nursing practice across the entire Army Medical Department. Bedside nurses in any MTF may now reach out to these subject matter experts from regional CNSCIs for assistance with patient care practice issues. The nurse clinical specialists working with nursing staff identify clinical issues, while the nurse informatics officers and nurse methods analysts facilitate maximal use of clinical information technology and business analytical tools in support of evidence-based practice initiatives. Additionally, each regional CNSCI has defined nursing research and evidence-based practice priorities, based on identified research focus areas, with the goal to transition from the past model often characterized as individual research interests to an integrated methodology addressing common bedside nursing practice issues. The nurse scientists assist nursing staff in the conduct of comprehensive literature reviews and evaluation of the strength of supportive evidence, and, if indicated, develop research protocols to build a body of knowledge if current evidence is lacking or inconclusive. In other, nonmilitary healthcare organizations, a similar strategy has been linked to quality care processes, as hospital-based nursing research cells provide the infrastructure and the processes to promote and sustain evidence-based practice. Such cells are also integral to the success of hospitals in the achievement of Magnet status, a marker of excellence in hospital care. (5) It is critical to success for nursing executive leadership in the organization to ensure that evidence-based practice language is incorporated in the mission, values, and philosophy of care, and that resources are made available to support the implementation.
Within the CNSCIs, the nursing scientists use the Iowa Model of Evidence-Based Practice framework (1) to assess the strength of the evidence supporting nursing practice changes. Each regional CNSCI conducts a thorough review of literature and grades the strength of the evidence. The Iowa Model of Evidence-Based Practice framework structures a decision making process evaluating available research, case reports, consensus of experts and scientific principles. Based upon the evidence, the nurse scientists may develop a nursing clinical practice guideline in collaboration with clinical nurse specialists and clinical nursing staff. If insufficient evidence exists, the nurse scientists may develop an appropriate research protocol in order to establish a body of knowledge ultimately sufficient to support standardization of clinical practice. If the practice guideline involves other non-nursing healthcare team members, recommendations are forwarded to the Army Medical Command proponent for clinical practice guidelines. The first application of this strategy involved the CNSCI nurse scientists assigned to the Madigan Army Medical Center, Tacoma, Washington.
Patient falls remain a prevalent problem in healthcare institutions, despite a plethora of literature related to the identification of at risk patients and actions to mitigate falls. Within the Army medical treatment facilities, the patient falls prevention strategy frequently differed as to risk assessment tools, documentation, and mitigation strategies. The challenge was to conduct an exhaustive review of the literature and grade the strength of evidence to determine the best practices that should then be standardized for each facility. The nurse scientists within the CNSCI were responsible for the initial review of the evidence and the development of the Falls Prevention Army Nursing clinical practice guideline (AN CPG) in collaboration with clinical nursing staff, clinical nurse specialists, and nursing leadership. Their findings, recommendations, and the Falls Prevention AN CPG were then forwarded to other regional CNSIs for review and validation. As concurrent with the Patient Falls AN CPG development, the Army Medical Command Patient Safety Section developed a Patient Falls prevention policy. The nursing practice guideline was then matched against the policy to ensure consistency in practice recommendations. The final products were the Falls Prevention AN CPG and the Army Medical Command Patient Safety policy standardizing the patient falls risk assessment tools for adults and children, risk mitigation actions, documentation, and outcome evaluative metrics.
Implementation of an evidence-based practice model in one institution is daunting. Building a framework for the sharing of evidence-based practice guidelines and enforcing their consistent application across several institutions can be overwhelming. Standardization of elements of nursing practice in multiple organizations worldwide requires not only the support of each nursing leader, but the administrative and communication processes necessary to disseminate and enforce implementation and systematic outcomes evaluation. Pearson et al (6) described the challenge of disseminating nursing innovations through large healthcare organizations comprised of multiple institutions. As a part of the Robert Wood Johnson Foundation initiative, Transforming Care at the Bedside (TCAB), 3 large healthcare systems were asked to evaluate how large hospital systems spread changes in nursing care processes across multiple medical surgical units within their institutions. They defined the term "spread" as the active dissemination of new ways to organize or provide care from one healthcare setting to another. The example initiative, evolved from concerns brought by frontline staff, was a change to facilitate smooth, safe, patient-centered nursing shift changes. One of the healthcare organizations involved in the TCAB initiative implemented a centralized or "top-down" approach to dissemination of specific innovations from one institution to another, whereby senior leaders introduced the innovation to a new location and encouraged staff nurses to implement changes. Conversely, the other 2 organizations used a "bottom-up" approach, whereby education on the TCAB improvement processes and team formation were provided to nursing staff, with staff nurses then responsible for implementation of the processes on their units. Both the top-down and bottom-up strategies for dissemination of practice innovations were equally effective. Both strategies required considerable resources and leadership support. The TCAB review team concluded that the top-down approach may be most useful when innovations have been previously implemented and tested, and the desire is to establish uniform, consistent adoption across the entire healthcare system. The advantage of the bottom-up approach is that it allows the nursing staff at unit level to effect the change with potentially more "buy-in" to the innovation.
Early in the development of the CNSCI concept, the Chief, Army Nurse Corps requested information on the strategy for dissemination of AN CPGs across all MTFs. In an impromptu discussion with the Corps Chief, the AN Corps Specific Branch Proponency Officer (AN CSBPO) diagrammed a process for generating nursing evidence-based practice priorities, the development of AN CPGs, and a review process involving senior nursing leaders. From this discussion, the Army Nurse Practice Council (ANPC) concept evolved as a method for senior nursing leaders across the Army Medical Command to prioritize nursing evidence-based practice initiatives and approve AN CPGs for dissemination and application into the nursing practice environment of our garrison MTFs and in our deployed healthcare settings. With multiple, worldwide MTFs, the centralized top-down strategy for dissemination of nursing practice innovations seemed the most feasible vehicle for AN CPG standardized application to each inpatient nursing unit. A charter for the ANPC defined its purpose: provide oversight and direction for nursing practice and nursing care delivery through standardization of evidence-based clinical practice guidelines within the domain of nursing. The ANPC is a deliberative body charged with providing recommendations to the Chief, Army Nurse Corps. The charter designated the AN CSBPO and the Army Medical Command Patient Safety Officer as ANPC cochairs with additional voting members, including the regional nurse executives, a medical brigade chief nurse, a nurse scientist from each region, and a senior enlisted advisor. As needed, the chairperson may invite subject matter experts to discuss specific topics within their area of expertise.
When the clinical inquiry cell has completed the review of the AN CPG, it is submitted to the ANPC chairperson who then distributes it to the ANPC membership for review and feedback. Based upon final recommendations, the AN CPG is subjected to ANPC vote. If approved by the majority of ANPC membership, the AN CPG is disseminated to each regional nurse executive for implementation across their region. An element of each ANPC review will be determination of performance and outcome metrics. The nurse method analysts and nurse informatics officers in the regional CNSCIs will assist in development of measurement tools, training aids, and improvements in the electronic medical record system to support the practice change. Multiple strategies have been implemented to ensure optimal dissemination of AN CPGs. The AN CPG is made accessible on the Army Medical Command Clinical Practice Guideline website (https://www.qmo.amedd.army.mil/pguide.htm). Additionally, each AN CPG will be incorporated into the web-based clinical training and competency assessment program available at each facility.
The establishment of the ANPC and the implementation of AN CPGs based on best evidence is a component of the Patient CaringTouch system of nursing care. Through standardization of many of our direct nursing care processes, the end state is the provision of consistent, evidence-based nursing care across all of our medical treatment facilities and reduce practice variance. The Falls Prevention AN CPG was the first nursing evidence-based practice guideline approved by the ANPC. An Army Medical Command operational order for the ANPC and AN CPG dissemination is currently in staffing. When approved, each additional AN CPG will be disseminated through operational order updates to the original operational order. Currently in development is a second practice guideline to standardize nursing processes and procedures as they relate to nursing hourly patient rounds, including standardized assessment of patients, interventions, documentation, and outcome metrics. To ensure that AN CPGs remain current and relevant, the CNSCIs and the ANPC will establish review dates for nurse scientists' proponents responsible for the review of literature and updates to previously approved AN CPGs. Recommendations will be reviewed by the ANPC membership for approval prior to the incorporation of changes.
Transitioning nursing practice from tradition-based to practice driven by evidence often requires a realignment of organizational structures. Nursing research cells were reorganized into regional CNSCIs and an ANPC was established to create an enduring infrastructure for the standardization of nursing practice based on best evidence across all of our healthcare institutions. While only in the beginning phase, the long-term goal is to ensure that patients in every Army healthcare facility receive nursing care within a standardized framework of evidence-supported clinical practice. That framework formalizes the linking of practice questions from nurses in direct patient care with a responsive infrastructure of clinical nurse specialists and nurse scientists to ensure facilitation of best-evidence answers.
(1.) Titler M, Kleiber C, Steelman V, et al. The Iowa model of evidence-based practice to promote quality care. Crit Care Nurs Clin North Am. 2001;13(4):497-509.
(2.) Melynk B, Fineout-Overholt E. Evidence-Based Practice in Nursing And Healthcare: A Guide to Best Practice. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2005.
(3.) Bondmass M. Implementation strategies for evidence-based practice. Nevada RNformation. 2011;20(1):14.
(4.) Staffileno B, Carlson E. Providing direct care nurses research and evidence-based practice information: an essential component of nursing leadership. J Nurs Manag. 2010;18:84-89.
(5.) Ingersol G, Witzel P, Qualls B. Meeting magnet and evidence-based practice expectations through hospital-based research centers. Nurs Econ. 2010;28(4):226-236.
(6.) Pearson L, Upenieks V. Spreading nursing unit innovation in large hospital systems. J Nurs Admin. 2008;38(3):146-152.
COL Carol J. Pierce, AN, USA
When this article was written, COL Pierce was the Army Nurse Corps Specific Branch Proponency Officer, AMEDD Center and School, Fort Sam Houston, Texas.
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