Creating a Culture of Evidence-Based Practice

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Certificate Program for Surgical Services Educators 7 Learning Module Creating a Culture of Evidence-Based Practice Author: Constance Melby, RN, MS, CNOR Operating Room Clinical Educator Trinity

1 Certificate Program for Surgical Services Educators 7 Learning Module Creating a Culture of Evidence-Based Practice Author: Constance Melby, RN, MS, CNOR Operating Room Clinical Educator Trinity Medical Center Moline, Illinois Contributor: Joanne McNeal, PhD, RN Lead Clinical Educator Trinity Medical Center Moline, Illinois Reviewer: Michelle Byrne, PhD, RN, CNOR Associate Professor and Coordinator of MS Nursing Education Program North Georgia College and State University Dahlonega, Georgia 1

2 Copyright 2010 by Competency & Credentialing Institute, Denver, Colo. ISBN: All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of the copyright owners. Printed in the United States of America 2

3 Table of Contents 7 Learning Module Unit 1: Introduction Objectives ANCC Accreditation Statement Background Unit 2: Models of Evidence-based Practice Unit 3: Initiating the Process Ask a Question Find the Best Evidence Critique the Evidence Integrate the Evidence Evaluate Effectiveness Components of a Research Article Unit 4: Unit-based Research Projects Research Designs Terminology Data Collection Data Analysis Reporting Outcomes Critique of Research Unit 5: Creating a Culture of Evidence-based Practice Conclusion Glossary of Terms References Appendices: 7-A: Sites for Obtaining Evidence-based Literature B: Descriptive Statistical Analysis Methods C: Sample Critique Form for Journal Club

4 Unit 1: Introduction 7 Learning Module It would be difficult for anyone currently practicing in nursing to not see the phrase evidence-based practice at least once during the course of a work week. But if asked for a definition, many nurses would be hard-pressed to provide an answer. Though perioperative nurses incorporate current best practice into their patient care plans every day, many do not realize it, or understand the rationale behind the action. As Captain von Trapp stated in The Sound of Music, I guess both of us are suffering from a deplorable lack of curiosity. The contents of this module suggest that curiosity is just as important as aseptic technique in the practice of safe patient care. Objectives Upon completion of this module, the participant should be able to: 1) Evaluate the components of a research article. 2) Differentiate between qualitative and quantitative studies. 3) Design opportunities to bring evidence-based practice to the unit. ANCC Accreditation Statement This continuing nursing education activity has been approved by the Association of perioperative Registered Nurses (AORN), an accredited approver by the American Nurses Credentialing Center s (ANCC) Commission on Accreditation. Activities that are approved by AORN are recognized as continuing education for registered nurses. This recognition does not imply that AORN or the ANCC Commission on Accreditation approves or endorses any product included in the presentation. Information on completing the Certificate Program for Surgical Services Educators and receiving continuing education may be found at and in the Certificate Program packet located in the inside pocket of the binder. Note: Credit will not be awarded unless activities for all seven modules are completed. Background Dr. David Sackett and colleagues (1996) first used the term evidence-based in an editorial in which the integration of research and practice was termed evidence-based medicine. However, it can be argued that 5

5 Unit 5: Creating a Culture of Evidence-based Practice 7 Learning Module Those who have recently attended the AORN Congress have heard of and likely attended the entertaining offering called the Quiz Bowl. In a game-show type atmosphere, teams compete to answer questions based on recent research. The audience is able to participate in some of the evidenced-based questions. The engaging atmosphere masks the fact that the entire audience is absorbing the wonderful information being shared through a quiz-show format. EBP concepts can be incorporated through a unit-based version of a quiz bowl. Monthly offerings in professional journals can provide summaries of current evidence affecting perioperative practice and serve as a great source of information for developing quiz questions. Another very popular event at Congress is the poster session, where hospitals from all over the world submit innovative ideas for best practice. Prizes are awarded based on the quality of the research design and the aesthetics of the presentation. This idea could be adapted at the unit level, where staff members create posters depicting patient care based on best practice. These could be posted in an area where other nursing colleagues would also benefit from the information. Asking managers and administrators to judge the posters would involve the entire hospital in the activity and help communicate the importance of EBP at all levels. Evidence-based practice should be a part of every educational program, beginning with orientation. Sources for references should be cited on slides, handouts, policies and procedures, and competencies. Consider implementing an evidence-based practice competency as part of the initial and ongoing requirements for staff. Putting links to search engines and a simple tutorial on searching databases in an easily accessed part of the hospital intranet will empower staff to conduct their own searches. Nurses in the operating room employing the Perioperative Nursing Date Set (PNDS) for documentation may not realize that they are using the end-product of a nursing research project. Extensive literature reviews were completed and a series of studies were conducted in the development of this standardized nursing language for use in surgical settings (AORN, 2009). Because many electronic management record systems have incorporated PNDS into their documents, orientation to computerized charting is a great platform for discussing implementation of research. A wealth of opportunities is available for learning and implementing EBP. Nurse educators must support both the process of research and the process of EBP within their staff. The promotion of evidence-based practice within organizations leads to the employment of practice standards that are built upon evidence. The influence of the nurse educator can support policy and procedure development with reference (i.e., evidence) requirements (Long, Burkett & McGee, 2009). A policy and procedure committee tasked with the review of policies can assess for the inclusion of evidence. The committee would have the authority to accept those submissions meeting expectations or ask for evidence in support of the outlined practice through 27

6 Unit 5: Creating a Culture of Evidence-based Practice references. These actions assist with entrenching EBP in the organization. Participation in infection control and department services committees, survey preparatory teams, and serving as a primary researcher for a hospital-based research project will all provide avenues for both mentoring and learning about the process. Volunteering to serve as a subject for a research project is another way to gain additional perspective on the process. Completing surveys and questionnaires sent by professional organizations is an easy way to contribute towards community research bases. EDUCATOR S PEARL To maximize attendance, offer nursing grand rounds during the lunch hour. Reserve a conference room, and arrange with administration to provide free meal vouchers for those attending. Providing or attending nursing grand rounds introduces EBP as a component of clinical expertise. Typically, nursing grand rounds involve a clinical issue, results of research, or a case study in which a patient s care is described based on current best practices. The presentation may range from a 5-minute discussion during a staff meeting, to a formal presentation offered hospital-wide in which continuing education credits are awarded. Empowering the clinical nurse to share a patient care example increases staff satisfaction and provides an opportunity to learn or improve presentation skills. The benefits of nursing grand rounds include supporting activities such as Magnet Status, clinical ladders, and other professional development initiatives (Lannon, 2005). Presentations may be videotaped for those unable to attend in person; providing handouts and an evaluation will enable those staff members to also obtain continuing education credit. Quality improvement activities often lead to the employment of evidence or practice guidelines. If evidence is embedded within practice changes, the changes are often more easily accepted and willingly practiced. Participation and personal involvement in these processes also increases investment in research and evidence-based practice. Participation in the American Nurses Credentialing Center s Magnet Recognition Program emphasizes the integration of nursing evidence-based practice throughout the institution. From the development of a shared decision-making model to the formation of an EBP team, the Magnet journey assists with the growth and vigor of evidence-based nursing. Nursing leadership may choose to embed EBP concepts into nursing job descriptions and performance appraisals. Those seeking advancement via a clinical ladder process can be exposed to opportunities to include EBP philosophies throughout all skill levels of nursing practice. Typically, the inclusion of EBP concepts increases as the ladder advances, seeking higher expectations from proficient and expert practice levels. One of the most popular methods of introducing staff to EBP is through a journal club. Journal clubs have long been a mainstay in academia as a way for students to reflect on and critique current literature. These skills also apply to the clinical setting, where additional benefits include increased research awareness, strengthened critical thinking skills, and improved professional reading habits (Thompson, 2005). Reading and critiquing research articles is a vital component of EBP and can serve as an impetus for the development of unit-based research. 28

7 Unit 5: Creating a Culture of Evidence-based Practice Typically a journal club is a voluntary monthly meeting at which assigned articles are discussed. The articles may be chosen by staff or the nurse educator. It is helpful to have someone knowledgeable about basic research terminology facilitate the meetings and guide discussion. The biggest barrier to journal clubs is time. Staff may find it difficult to have a face-to-face meeting due to schedules and patient care responsibilities. It will take creativity on the nurse educator s part and support from management to make a journal club successful. Consider videotaping a session; it can then either be placed on the hospital intranet or on the closed-circuit TV system so that staff members could watch it whenever they had the opportunity. Announce the title of the article and provide an critique form well in advance so that members can feel like a part of the group. Use report to introduce the article; provide one or two sentences about the article and a critique form. Post the article in the lounge with extra copies of the form. Consider making a bulletin board specifically for EBP. Look at where people congregate the scrub sinks, the lounge, and the dressing rooms and post abstracts to pique interest. Ask a staff member to present an article during a staff meeting. Use the employee system to send out articles and critique forms. Some systems will support a chat room or discussion-board type of format where staff can respond to each others comments. The development of a tool to critique journal articles is key to the success of a Journal Club. It should be simple, quick and easy to fill out, and logically organized. Consider providing definitions for frequently encountered terms (e.g., independent/dependant variables, p values) as part of the form. A sample critique form is provided in Appendix 7-C. The Discern instrument and handbook (Discern Online, 1997) is a free on-line tool that has been developed to allow consumers to evaluate the quality of written treatment options; because it follows the format of critiquing an article, it is applicable for professionals in the clinical setting also, and may serve as a userfriendly evaluation tool for unit-based journal clubs. It may be used without permission as long as the instructions are followed. Dearholt, White, Newhouse, Pugh, & Poe (2008) suggested a novel idea for instituting a nursing fellowship that provides funding for nurses to work one or two days a week on an evidence-based practice project. For facilities that cannot support this time commitment, half-day time allotments may be more fiscally possible. For hospitals with a shared governance model, the nurse practice committee may be able to develop a scholarship fund for which nurses interested in conducting a study can apply. 29

8 Unit 5: Creating a Culture of Evidence-based Practice Conclusion The nurse educator serves as a mentor for implementing EBP in the clinical setting. As nurses become familiar with concepts and accrue knowledge of EBP processes, confidence grows. A vital component of nursing today is the inclusion of evidence-based practices. For the continued growth of the nursing profession, and for the provision of excellence in care for patients, research and evidence-based care must be embraced. Nurse educators can greatly influence present and future successes. The primary role of the nurse educator in the research process is to promote and nurture a climate that embraces change, as that frequently is the end result of an evidence-based activity. Staff must be supported and encouraged to ask questions, and then participate in finding the answers. Time to work on research projects needs to be factored into the staff nurses workload. The nurse educator may need to provide assistance in developing a clearly written report that supports the recommended guidelines; this is the most credible way of demonstrating the need for change. Serving as a champion for establishing a culture of inquiry and being familiar with available resources are the most useful skills a nurse educator can bring to the role. 30

9 References 7 Learning Module American Nurses Association (ANA). Safe staffing saves lives: National Database of Nursing Quality Indicators (NDNQI ). Retrieved Dec. 30, 2009 from OneMinuteEssays/NDNQI.aspx. Association of perioperative Registered Nurses (AORN). (2009). PNDS History & Mission. Retrieved July 31, 2009 from Beck, C.T. (2009). Viewing the rich, diverse landscape of qualitative research. Perioperative Nursing Clinics, 4(3), The Cochrane Library. accessed July 19, Dearholt, S. L., White, K.M., Newhouse, R., Pugh, L.C., & Poe, S. (2008). Educational strategies to develop evidence-based practice mentors. Journal for Nurses in Staff Development, 24(2), Discern Online. (1997). The Discern Instrument. Retrieved Dec. 28, 2009 from uk/index.php. Hoss, B., & Hanson, D. (2008). Evaluating the evidence: Web sites. AORN Journal 87(1) Houser, J., & Bokovoy, J. (2006). Clinical research in practice; A guide for the bedside scientist. Boston, MA: Jones and Bartlett Publishers. Institute of Medicine. (2001). Crossing the Quality Chasm: A new health system for the 21st century. Retrieved Sept. 23, 2009 from Lannon, S.L. (2005). Nursing Grand Rounds: Promoting excellence in nursing. Journal for Nurses in Staff Development, 21(5), Leufer, T., & Cleary-Holdforth, L. (2009). Evidence-based practice: Improving patient outcomes. Nursing Standard, 23(32), Levin, R.F. & Feldman, H.R. (2006). Teaching evidence-based practice in nursing. New York,NY: Springer Publishing Co. 33

10 References Long, L.E., Burkett, K.W., & McGee, S. (2009).Promotion of safe outcomes: Incorporating evidence into policies and procedures. Nursing Clinics of North America, 44(1), Melnyk, B., & Fineout-Overholt, E. ( 2005). Evidence-based practice in nursing and healthcare; A guide to best practice. Philadelphia,PA: Lippincott Williams &Wilkins. Montalvo, I. ( 2007). The National Database of Nursing Quality IndicatorsTM (NDNQI ) OJIN: The Online Journal of Issues in Nursing, 12(3), Manuscript 2. Retrieved Dec. 30, 2009 from MenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/ NursingQualityIndicators.aspx. National Center for Educational Statistics. Create a graph. Retrieved Sept. 26, 2009 from ed.gov/nceskids/createagraph/default.aspx. National Institutes of Health.(2000). Decision tree for how to proceed with review and approval of research involving human subjects. Retrieved Dec. 29, 2009 from National Institutes of Health, Office of Human Subjects Research.(n.d.) Regulations and ethical guidelines: Nuremberg Code. Retrieved Dec. 29, 2009 from Nieswiadomy, R. (2008) Foundations of nursing research (5th ed.). NJ: Pearson Prentice Hall. Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New York, NY: Dover Publications, Inc. Originally published in 1860 by D. Appleton and Co. Sackett, D.L., Rosenberg, W., Muir Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based medicine: What it is and what it isn t. British Medical Journal, 312,(7023), Scott, K., & McSherry, R. ( 2008). Evidence-based nursing, clarifying the concepts for nurses in practice. Journal of Clinical Nursing, 18, Schultz, S., Dell, E., Bodan, C. (2009)Are we there yet? When is a literature review complete? American Journal of Nursing, 109(9), Siedlecki, S.L. (2008). Making a difference through research. AORN Journal, 88(5), Stevens, K. (2004) ACE Star Model of EBP: Knowledge Transformation. Accessed July 26, Thompson, C.J. (2006). Fostering skills for evidence-based practice: The student journal club. Nurse Education in Practice, 6, Titler, M., Kleiber,C., Steelman, V., Rakel, B., Budreau, G., Everett, L., Buckwalter, K. (1998). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Retrieved Aug. 6, 2009 from uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/iowamodel.html. 34

11 References Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law (1949). 10(2), pp Washington, D.C.: U.S. Government Printing Office. Retrieved July 27, 2009 from University of Idaho. (2009). Information literacy. Retrieved from edu/info%5fliteracy/. US Department of Health and Human Services Agency for Healthcare Research and Quality. ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm. Accessed September 27, Additional Resources AORN. (2009). Perioperative nursing clinics: Research, 4(3). Philadelphia, PA: Elsevier. Bradley, D., & Dixon, J.F. (2009). Staff nurses creating safe passage with evidence-based practice. Nursing Clinics of North America, 44, Bruscoe, J. (2009). Exploring the AORN Journal web site. AORN Journal, 90(6), Campbell-fleming, J., Catania, K., & Courtney, L (2009). Promoting Evidence-Based Practice through a traveling journal club. Clinical Nurse Specialist, 23(1), 16-`20. Carlson, D. S., Masters, C., & Pfadt, Ellen. Guiding the clinical nurse through research publication development. Journal for Nurses in Staff Development, 24(5), Definitions of Evidence-Based Practice. Retrieved Nov. 20, 2009, from def.html. Evans, D. (2003). Hierarchy of evidence: A framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12, Fineout-Overholt E., Baldwin, C.,& Greenberg, E. ( 2009). Evidence-Based Practice in the Holistic Nursing Process. American Holistic Nursing Association. Retrieved Dec. 30, 2009 from Research/ArticleLibrary/EvidenceBasedPractice/tabid/5572/Default.aspx. Gutman, S. (2009). How to Appraise Research: Elements of Sound Applied Design. The American Journal of Occupational Therapy, 63(2), Hanson, D., Hoss, B., & Wesorick, B. (2008) Evaluating the Evidence: Guideline. AORN Journal, 88(2), Harne-Britner, S., & Schafer, D.J. (2009). Clinical Nurse Specialists driving research and practice through research roundtable. Clinical Nurse Specialist, 23(6),

12 References Heye, M., Stevens, K. (2009, June) Using Resources to Teach Evidence-Based Practice. Journal of Nursing Education, 48(6), Hanna, L.A. (2009). The use of statistical control charts to monitor and improve the management of education department resources. Journal for Nurses in Staff Development, 25(3), Horsely, J. A. (1983). Using research to improve nursing practice. New York : Grune and Stratton. (Note: Considered the definitive work on research utilization; used copies are available.) Lawrence, J. (2007, April) Techniques for Searching the CINAHL Database Using the EBSCO Interface. AORN Journal, 85(4), Krugman, M. (2003). Evidence-based practice: The role of staff development. Journal for Nurses in Staff Development, 19(6), MacDermid, J., Walton, D., & Law, M. (2009) Critical Appraisal of Research Evidence for Its Validity and Usefulness. Hand Clinics, 25, Melnyk, B., Fineout-Overhold, E., Stillwell, S.B., & Williamson, K.M. (2009). Igniting a spirit of inquiry: An essential foundation for evidence-based practice. AJN, 109(11), Milner, F. M., Estabrooks, C.A., & Humphrey, C. (2005). Clinical nurse educators as agents for change: Increasing research utilization. International Journal of Nursing Studies, 42, Mohide, E. A., & Coker, E. (2005). Toward clinical scholarship: Promoting evidence-based practice in the clinical setting. Journal of Professional Nursing,21(6), Nursing Executive Center. (2005). Evidence-based nursing practice, Instilling rigor into clinical practice. Washington, D.C.: The Advisory Board. Polit, D.,& Tatano Beck, C. (2006). Essentials of nursing research; Methods, appraisal, and utilization (6th ed.). Philadelphia, PA: Lippincott Williams &Wilkins. Polit, D., & Tatano Beck, C. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Walters Kluwer/Lipincott Williams &Wilkins. Phillips, J. et al. (2006). Where s the evidence? An innovative approach to teaching staff about evidencebased practice. Journal for Nurses in Staff Development, 22(6), Sherrod, R.A., Ford, C., & Oliver, J. (2010). Using data from the internet to teach ethical principles for critiquing research studies. Nurse Educator, 35(1), Stelmach, E.I. (1994). Practical innovations: A staff journal club as a method of continuing education. AORN Journal, 59(5),

13 References University of Minnesota Libraries. Evidence-Based Practice. Retrieved Dec. 23, 2009 from biomed.lib.umn.edu/learn/ebp/mod01/index.html. (Note: This is a tutorial that walks through the 5 steps for EBP.) Examples of Peer-Reviewed Evidence-based Research Caricich, G.M., & Rafti, K.R. (2007). Experienced Registered Nurses satisfaction with using self-learning modules versus traditional lecture/discussion to achieve competency goals during hospital orientation. Journal for Nurses in Staff Development, 23(5), Espin, S.L.,& Lingard, L.A. (2001). Time as a catalyst for tension in nurse-surgeon communication. AORN Journal, 74(5), Pravikoff, D.S., Tanner, A.B., & Pierce, S. T. (2005). Readiness of U.S. nurses for evidence-based practice. American Journal of Nursing, 105(9), Rogers, J. (2009). Transferring research into practice: An integrative review. Clinical Nurse Specialist, 23(4),

Objectives. EBP: A Definition. EBP: A Definition. Evidenced-Based Practice and Research: The Fundamentals. EBP: The Definition

Objectives. EBP: A Definition. EBP: A Definition. Evidenced-Based Practice and Research: The Fundamentals. EBP: The Definition Objectives Evidenced-Based Practice and Research: The Fundamentals March 22, 2011 EBP Boot Camp Presentation by Cynthia A. Oster, PhD, MBA, RN, CNS-BC, ANP Upon completion of this educational activity,