Improving the Adoption of Evidence-Based Practice Among Nurses in Army Outpatient Medical Treatment Facilities

Transcription

1 MILITARY MEDICINE, 178, 9:1002, 2013 Improving the Adoption of Evidence-Based Practice Among Nurses in Army Outpatient Medical Treatment Facilities COL Edward E. Yackel, AN USA*; Nancy M. Short, DrPH, MBA, RN ; COL Paul C. Lewis, AN USA ; COL Sara T. Breckenridge-Sproat, AN USA ; Barbara S. Turner, PhD, RN, FAAN ABSTRACT This quality improvement project implemented and evaluated an evidence-based practice (EBP) program at two Army outpatient health care facilities. The EBP program consisted of five implementation strategies that aimed to inculcate EBP into organizational culture as well as nursing practice and culture. A conceptual model of the Diffusion of Innovations theory was adapted to explain the application of the program. The Institutional Review Boards at Walter Reed National Military Medical Center and Duke University School of Medicine reviewed and exempted this quality improvement project. A pretest posttest design was used with four instruments at each facility. The EBP program was successful in enhancing organizational culture and readiness for EBP ( p < 0.01) and nursing staff s belief about the value of EBP and their ability to implement it (p < 0.05). Another indicator that the EBP program achieved its goals was the significant difference ( p = 0.002) in the movement of the outpatient health care facilities toward an EBP culture. These results suggest that this EBP program may be an effective method for empowering outpatient nursing staff with the knowledge and tools necessary to use evidence-based nursing practice. BACKGROUND AND IMPORTANCE Evidence-based practice (EBP) is defined as a process in which scientific evidence, clinician expertise, and patient s values and preferences are incorporated into practice settings. 1 The EBP process has five-steps: developing a clinical question, searching for evidence, appraising the evidence, implementation, and evaluating practice recommendations for change. 2 EBP is patient centered and associated with higher quality nursing care, better patient outcomes, and increased professional role satisfaction. 3 5 Despite consumer pressure, government reports, and support by health care leaders, the integration of EBP into clinical practice remains inconsistent. 5 The leadership of the Army Nurse Corps is committed to fostering EBP and has established it as one initiative in a system of care known as the Patient Caring Touch System (PCTS). The PCTS also establishes shared accountability via both unit and facility level nurse practice councils. These councils represent nursing staff from the primary and specialty care clinics within a medical treatment facility (MTF) and are responsible for making recommendations to improve clinical practice. Although EBP has been adopted by the practice councils at inpatient MTFs, it has been inconsistently used by practice councils who work in the 34 freestanding Army Medical Department (AMEDD) outpatient facilities. *Department of Clinical Operations, San Antonio Military Health System, 7800 I-10 West, San Antonio, TX Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI The views and opinions expressed in this article are solely those of the authors and do not necessarily reflect those of the U.S. Army, the Department of Defense, or the U.S. Government. doi: /MILMED-D The literature identifies multiple strategies for EBP programs, such as developing EBP mentors, adapting performance standards to reflect EBP as an expectation of nursing practice, educating nursing staff about EBP, and involving leadership in allocating the resources necessary (time, money, and staffing) to implement and sustain EBP. 6 8 These strategies have some empirical evidence to support them in the inpatient setting; however, research on strategies to create a culture embracing EBP across various health care settings is limited. 9 Therefore, this project explored EBP implementation strategies in an outpatient health care setting. The purpose of this project was to implement an EBP program in two Army outpatient treatment facilities. The program consisted of five strategies with the goals to (1) strengthen nursing participants beliefs about the value of EBP and their ability to engage and implement it; (2) improve nursing participants understanding of their role in mentoring others in EBP; (3) measure the influence of the EBP program on nursing culture; (4) enhance organizational culture and readiness for EBP; and (5) capture policy recommendations that facilitate the dissemination of EBP throughout all Army outpatient health care facilities. METHODS This project took place at two Army outpatient facilities located in Virginia over a 6 month period from June 2012 to February The facilities, referred to as MTF A and MTF B, each served a population of approximately 30,000 patients comprised of Active Duty service members, family members, and retirees. MTF A had 12 clinics and MTF B had 8 clinics employing a mixture of direct care military and civilian nursing staff (N = 295). These direct care nurses consisted of Certified Nursing Aides (CNAs), Army Medics, Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). Each of the MTFs had Unit and Nurse Practice 1002 MILITARY MEDICINE, Vol. 178, September 2013

2 Councils. The members of the Unit Practice Councils are elected by their peers. Membership is reflective of the mix of the entire nursing team. The membership of the Nurse Practice Councils is the Clinical Nurse Officers-in-Charge (Head Nurses), a Master s prepared nurse educator, and an Advanced Practice Registered Nurse (APRN). Participants in the EBP program were volunteers from the Unit and Nurse Practice Councils. The anonymity of participants was maintained by deidentifying data, having a third-party collect survey data, storing electronic data on a secure server, and not linking surveys with individual names. Both MTF A and B had computers, internet access, and conference space. However, neither of the MTFs had an on-site medical library. The AMEDD provides a virtual library with EBP resources, but nursing staff were unaware of how to navigate to this asset. This quality improvement project used a pretest-posttest design because randomization to a control group was not feasible. Theoretical Framework and Model Diffusion of Innovations is a theory that seeks to explain how, why, and the rate at which new ideas spread through cultures. 10 Greenhalgh et al describe a conceptual model for the spread and sustainability of innovations that is based on a systematic review of the literature on the diffusion and spread of innovations in organizations. Figure 1 provides an illustration of the application of Diffusion of Innovations to the EBP program. First Strategy: Involve Leadership Leaders within organizations are critical in creating a cultural context that fosters innovation, and establishing organizational strategies that facilitate innovations. 10 Organizations that develop a strategic plan to integrate EBP into clinical practice are more likely to have success in implementing EBP. 11,12 FIGURE 1. Diffusion of Innovations: The EBP program. The characteristics of an innovation such as the relative advantage (over existing practices), compatibility (with existing practices), complexity (how difficult the innovation is to understand), and trialability (tested on a limited basis) influence the rate and extent of adoption by individuals. (From Greenhalgh T, Robert G, Bate P, Macfarlane F, Kyriakidou O. Diffusion of Innovations in Health Service Organizations, p 201), Oxford, UK, Blackwell Publishing, Adapted with permission.). MILITARY MEDICINE, Vol. 178, September

3 This project began by providing information briefings to the Chief Executive, administrative personnel, and medical personnel of the MTFs. The briefings outlined the EBP program, the benefits of evidence-based nursing practice, and the resources (time, money, staffing) needed to implement the program. The leadership of both MTFs approved the EBP program and assigned a member of the leadership team to assist in its execution. A multidisciplinary team at MTF A developed strategic planning documents over a 6-month period. Subsequently, the leadership of MTF B reviewed these documents to determine if they could be standardized and adopted by other Army outpatient MTFs. Second Strategy: Provide EBP Education Sharing knowledge facilitates the diffusion of innovations. 10 Melnyk et al 13 suggest that strategies such as educational sessions on EBP should strengthen nurses beliefs about the value of EBP and their ability to implement it. A sample (n = 75) of nursing staff (CNAs, Army Medics, LPNs, RNs, and APRNS) from each facility that were current or newly elected members of Unit Practice Councils, voluntarily participated in one of seven introductory EBP education sessions titled: EBP 101. The goal for EBP 101 was to strengthen participants beliefs about the value of EBP and their ability to engage and implement it. Doctorally prepared nurse experts validated the content of EBP 101 and the same instructor presented the material, with assistance from the Nurse Educator at each facility, to ensure fidelity of the information. Nursing staff received continuing education credits as an incentive to attend EBP 101 and completed course feedback forms. Third Strategy: Conduct an EBP Mentorship/Champion Program Mentorship has been closely linked to the implementation and sustainment of an EBP culture 4 and must be used in conjunction with education to enhance clinicians EBP beliefs. 3 Having EBP mentors and champions promotes a hands-on approach to implementation, dissemination through expert opinion, encourages internal communication and collaboration, and facilitates knowledge transfer. A sample (n = 21) of baccalaureate or master s prepared RNs who were current or new members of a Nurse Practice Council voluntarily participated in an EBP 201 course. The goals of EBP 201 were to (1) strengthen the participants belief about the value of EBP and his/her ability to engage and implement it and (2) improve the participants understanding of his/her role in mentoring others in EBP. To attend EBP 201, participants had to complete two prerequisites: participants attended EBP 101 to establish a common knowledge platform, and verbally acknowledged reviewing the Army Nurse Corps Mentoring Program Handbook. 14 Doctorally prepared nurse experts validated the content of EBP 201. Delivery of the curriculum occurred via video or audio teleconferencing and a 1-hour discussion occurred in which participants reviewed the responsibilities of being an EBP champion and mentor. Nursing staff received additional continuing education credits as an incentive to attend EBP 201 and completed course feedback forms. Fourth Strategy: Revise Performance Standards Smith and Donze 2 note that an organizational infrastructure that embraces EBP must have policies, job descriptions, and performance appraisals that emphasize the importance of EBP. Consequently, clinical nurse leaders and a human resource associate met at each MTF to develop standardized EBP performance standards for nursing staff. This process took 4 months to accomplish. The corresponding (E.E.Y.) author provided background information on the importance of evidence-based nursing practice and the implementation of the EBP program to provide a context for the revision of the performance standards. Clinical nurse leaders at MTF A agreed to develop the performance standards and clinical nurse leaders at MTF B agreed to review the standards to determine if they could be adapted and applied to nursing staff working in other Army outpatient MTFs. Fifth Strategy: Create a Computer Shortcut It is critical that nurses have access to EBP resources at the clinic level to learn about and practice EBP. 2,11 Since neither MTF had an on-site medical library, creating a desktop shortcut that linked nursing staff to the AMEDD virtual library became the fifth strategy in the EBP program. This strategy intended to give nursing staff an opportunity to use a tool at the point of care, enhance access to evidencebased clinical products, and decrease the complexity of finding information. Nursing staff who attended EBP 101 received instruction on how to create a shortcut to the AMEDD virtual library on their computer desktops. The corresponding author asked participants to voluntarily assist their coworkers in creating the shortcut and to keep a count of how many staff members created the shortcut. The nurse educators collected the counts from the participants and reported the total counts for each facility. INSTRUMENTS Participants completed four valid and reliable surveys in this project. Administration of the instruments and data storage occurred via a secure Web-based application that adhered to security protocols. The Organizational Culture and Readiness for Systemwide Integration of Evidence-based Practice (OCRSIEP) scale is a 25-item scale that measures the extent that cultural factors influence system-wide implementation of EBP and the overall perceived readiness to integrate EBP compared to 6 months ago. 4,5 Respondents indicate their agreement with each item on a 5-point Likert scale with 1 = none at all and 5 = very much. Items are summed to create a total score ranging from 25 to 125. Higher scores reflect greater organizational readiness for EBP. The scale has established face 1004 MILITARY MEDICINE, Vol. 178, September 2013

4 and content validity, with internal consistency reliabilities of >0.85 and Cronbach s a ranging from 0.88 to 0.94 in studies conducted by Melnyk et al 4 and Wallen et al. 5 Kennerly et al 15 developed the Nursing Culture Assessment Tool (NCAT) because they found that existing instruments typically focus on organizational culture instead of subcultures such as nursing. The authors collected survey data from a sample (n = 340) of RNs (170), LPNs (83), and CNAs (87). The NCAT has 19 items that are summed to produce a score with a range from 19 to 76. The total NCAT summed score is calculated by summing the numerical value to each answer (strongly disagree = 1, disagree = 2, agree = 3, and strongly agree = 4). Higher total scores (57 76) reflect a positive perception of nursing culture. 15 The Cronbach s a for the NCAT total scale was 0.92, which was deemed adequate to support the NCAT s use in assessing worker perceptions of nursing culture in a wide variety of inpatient and outpatient health care settings. 15 Melnyk et al developed and established the psychometric properties of the EBP Beliefs (EBPB) and Implementation (EBPI) scales by surveying nurses (N = 394) who attended EBP workshops. The 16-item EBPB scale measures a person s belief about the value of EBP and the ability to implement it. The items are measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Item scores are summed with a range of scores from 16 to 80. Higher scores indicate stronger beliefs about EBP. A Cronbach s a of 0.90 was established for internal consistency reliability. 13 The EBPI scale is an 18-item Likert scale designed to measure indicators of nurse s engagement in EBP. For each item, respondents rate the frequency that they performed a particular task related to EBP over the past 8 weeks. Item scores are summed for a total score that can range from 0 to 72. Higher scores indicate greater implementation of EBP. A Cronbach s a of 0.96 was established for internal consistency reliability. 13 Ten demographic questions were administered with the EBPB and the EBPI surveys to determine sample characteristics. RESULTS The significance level was set at p < 0.05 for all statistical calculations. A two sample pretest-posttest design was used for this project because we were unable to match participant s responses before and after the surveys were administered. OCRSIEP Survey The OCRSIEP survey was used to measure the extent that cultural factors influence system-wide implementation and the overall perceived readiness to integrate EBP 4,5 at both MTFs from pre- to post-ebp program implementation. A single summed score was calculated. All clinical staff (MTF A: N = 336; MTF B: N = 204) were surveyed 3 weeks before the EBP program was initiated and resurveyed 4 months later. A two sample t test revealed a significant increase in average score for this survey from preintervention (mean = 51.26, SD = 15.89) to postintervention (mean = 55.06, SD = 15.62; t(504) = 2.65, p < 0.01). A two sample t test was also conducted to examine differences between the two facilities involved in the implementation. Results revealed no significant difference between the facilities on their overall OCRSIEP scores pre- and postintervention. Exploratory item analyses were conducted to group differences on specific items that might have been concealed when comparing overall scores. Table I shows item means and standard deviations, and group difference test statistics for items that were significantly different between pre- and post-ebp program time points. Nursing Culture Assessment Tool The NCAT 15 was used to measure the overall change in nursing culture from pre- to post-ebp program implementation. All nursing staff (MTF A: N = 189; MTF B: N = 104) were surveyed 3 weeks before the EBP program was initiated and resurveyed 4 months after the initial survey. Participant s responses to each of the items were summed and the means of those summed scores were compared for the pre-ebp (n = 132) and post-ebp program (n = 127) implementation TABLE I. OCRSIEP Scale: Items With Significant Mean Score Change From Baseline to Post-EBP Program Baseline Postprogram t Test OCRSIEP Items Mean (SD) Mean (SD) Value To what extent is the nursing staff with whom you work committed to EBP? 3.40 (1.22) 3.62 (1.15) 2.07* To what extent are there administrators within your organization committed to EBP? 3.36 (1.21) 3.68 (1.17) 2.95** In your organization, to what extent is there a critical mass of nurses who have strong 3.06 (1.19) 3.34 (1.08) 2.66** EBP knowledge and skills? To what extent are there nurse scientists in your organization to assist in generation of 2.34 (1.34) 2.62 (1.35) 2.25* evidence when it does not exist? In your organization, to what extent are there Advanced Practice Nurses who are EBP 2.55 (1.30) 2.91 (1.31) 3.03** mentors for staff nurses? To what extent do staff nurses have proficient computer skills? 3.60 (1.00) 3.83 (1.01) 2.51* To what extent do librarians within your organization have EBP knowledge and skills? 2.04 (1.35) 2.32 (1.45) 2.15* Compared to 6 months ago, how much movement in your organization has there been toward an EBP culture? 2.92 (1.27) 3.26 (1.19) 3.09** *p < 0.05; **p < MILITARY MEDICINE, Vol. 178, September

5 time points. Results revealed no significant change in NCAT total score from pre-to post-ebp program. Evidence-based Practice Surveys The EBPB and EBPI surveys were used pre- and post-ebp 101 sessions and EBP 201 course. Those nurses who attended both EBP 101 and EBP 201 were only surveyed before and after the EBP 201 course. A total of N = 78 (n = 38 at MTF A and n = 40 at MTF B) complete data sets were retrieved from the electronic database. On further analysis of attendance at the EBP 101 sessions and EBP 201 course, it was evident that some of the nursing staff may have responded to the electronic surveys more than once. For the purpose of statistical calculations we set N = 78. Participants from both MTFs responded to the EBPB and EBPI survyes 13 : n = 38 at MTF A and n = 40 at MTF B. The questionnaires were administered 1 week pre- and 1 week post-ebp 101 sessions and EBP 201 course. Demographic items showed that most respondents were RNs (N = 33, 41.3%) or LPNs (N = 25, 31.3%) with an average of 17.2 years in nursing practice. The majority of nursing staff worked in a primary care clinic (52.5%), 82% was female, had a mean age = years, and 86% were civilian employees. Of note, 56% of participants reported prior education or training on EBP. To compare participants beliefs about the value of EBP and their engagement in EBP before and after the implementation, two sample t tests were conducted separately for the EBP 101 sessions and the EBP 201 course samples. Regarding the EBP 101 sessions, results revealed a significant difference in EBPB scores pre-education (mean = 52.04, SD = 5.66) and posteducation (mean = 56.04, SD = 7.22; t(44) = 2.08, p < 0.05). Although, the EBPI scores also increased for pre-education (mean = 26.04, SD = 12.38) and posteducation (mean = 34.04, SD = 16.96; t(42) = 1.79, p = 0.08), they did not achieve a statistically significant difference. To examine differences between the types of personnel (Army Medic, CNA, LPN, RN) on EPB beliefs and engagement, a series of ANOVAs were conducted to compare providers in the EBP 101 sessions and EBP 201 course at pre- and postintervention time points. There were no significant differences found between EBP 101 session personnel or the EBP 201 course personnel on EBPB or EBPI scores at the pre- or postintervention time points. Based on the small sample size (N = 10) for the 201 course, Mann Whitney U tests were conducted to compare EBPB and EBPI scores pre- and postcourse implementation. Results revealed a trend toward significance difference in EBPB scores precourse (mean rank = 3.80) and postcourse (mean rank = 7.20); Mann Whitney U test = 4.00, p = There was also a trend toward significance in EBPI scores precourse (mean rank = 3.70) and postcourse (mean rank = 7.30; Mann Whitney U test = 3.50, p = 0.06). Several products resulted from the implementation of the five strategies that comprised the EBP program: (1) development and approval of strategic planning documents occurred; (2) synthesis of participant s responses on course feedback forms (Table II) resulted in recommendations for improving the courses; (3) clinical nurse leaders developed five performance standards that established EBP as an expectation of nursing practice; and (4) nursing staff that assisted their coworkers in establishing a desktop shortcut to the TABLE II. Course Feedback for EBP 101 and 201 EBP 101 Scores Scale: 1 5 (Low to High) n = 73 a (Not All Participants Answered Every Question) Totals Objective 1: Define EBP Objective 2: Describe Examples of Nursing EBP and Research Objective 3: Identify Goals of EBP Objective 4: Describe the Step in the EBP Process Objective 5: Describe the Application of EBP Into Clinical Practice Objective 6: Describe the Essential Components in Evidence Appraisal Objective 7: Explain the Challenges and Misconceptions of EBP Objective 8: Use Resources to Further Knowledge of EBP EBP 201 Scores Scale: 1 5 (Low to High) n = 21 (Not All Participants Answered Every Question) Objective 1: Define EBP Objective 2: List EBP Models Objective 3: Appraise the Evidence Objective 4: Use the Iowa Model or PDSA (Plan, Do, Study, Act) Objective 5: List 5 Steps of EBP Objective 6: Identify Whether a Project Needs Insitutional Review Board Approval or Public Affairs Clearance Objective 7: Implement a Project at Your Command Objective 8: Mentor Others as an EBP Knowledge Broker Participants graded themselves on a scale from 1 (low) to 5 (high) on their ability to meet the course objectives. There were no scores of 1 or 2. A majorityof participants gave themselves a score of 4 or 5. This means for EBP 101 > 92% respondents gave themselves a 4 or 5 and for EBP 201 > 82% of respondents did the same. a N = 75 attendees at the EBP 101 sessions MILITARY MEDICINE, Vol. 178, September 2013

6 TABLE III. Products of the Intervention Strategies Product Name Responsible Party Outcomes Strategic Plan Developed by a focus group (business, clinical, and leadership team members) at MTF A and reviewed by the leadership of MTF B who deemed that the plan was amenable to adoption by other Army outpatient MTFs. EBP integrated into the organization s strategic management system. EBP became an organization level process improvement initiative. A Commander s Policy Letter was written to Performance Standards Computer Shortcut Developed by nurse leaders at MTF A and reviewed by nurse leaders at MTF B who determined that the performance standards could be adopted and applied to nursing staff working in other outpatient MTFs. Nursing staff who attended the EBP 101 sessions at both MTFs. communicate the importance of EBP. Five performance standards were developed and integrated into the performance evaluation documents for all nursing staff. The performance standards were submitted to an AMEDD level nursing committee for inclusion into a set of performance standards for ambulatory nursing. MTF A: N = 183 coworkers assisted (self-report) a MTF B: N = 42 coworkers assisted (self-report) a The Information Management Divisions at both MTFs are working on a desktop shortcut for all clinical staff. a It is recognized that self-reporting is an inherently unreliable measure, but the reports by nursing staff from both MTFs indicate commitment and engagement in EBP. AMEDD virtual library reported helping 225 coworkers. The products are further described in Table III. DISCUSSION The results of the OCRSIEP survey suggest that the EBP program was successful in enhancing organizational culture and readiness for EBP. Several of the selected set of items that were significantly different between pre- and post-ebp program time points (Table I) are noteworthy. Nursing staff s commitment to EBP might have increased because of the EBP 101 sessions. This assumption is supported by the scores on the EBPB survey that showed a significant difference in scores pre- and post-ebp 101 sessions. The EBP 101 sessions might also be the reason that participants felt that there was a critical mass of nurses who have strong EBP knowledge and skills, that there were administrators within the organization committed to EBP, and that nurse scientists were available to assist in generating evidence. The course content for the EBP 101 sessions supported the acquisition of knowledge and skills (such as hands-on computer searches of the AMEDD virtual library), educated participants about leadership support for EBP, and made them aware that a nurse scientist was available to support their EBP endeavors. Participants in the EBP 101 sessions were also made aware that APRNs such as Family Nurse Practitioners were knowledgeable about EBP and could mentor others. Perhaps the most noteworthy indicator that the EBP program achieved its goals was the significant difference (p = 0.002) in the movement of the MTFs toward an EBP culture compared to 6 months ago. The products that emerged from the implementation of the five strategies might have contributed to this result. It should be noted that AMEDD and regional medical command support for EBP was prominent during the EBP project implementation time frame, which may have influenced the results. A review of the responses to the pre- and post-ncat surveys revealed that a majority of the nursing staff either agreed or strongly agreed to a majority of the questions. Since the responses of agreed and strongly agreed receive the maximum points for scoring, a higher total score is difficult to achieve. This explains why there were no significant differences in NCAT total scores from pre-to post-ebp program. In contrast to Varnell et al 16 who used the EBPB and EBPI scales and found that preintervention participants who had advanced degrees or who worked in advanced roles were more likely to implement EBP, we found no differences between nursing staff who attended the EBP 101 sessions or the 201 course at the pre- or postintervention time points. A possible explanation for our findings is that 56% of participants in the EBP 101 sessions and EBP 201 course reported having prior education or training on EBP before the implementation of the EBP program. However, anecdotal reports from these same nursing staff suggest that the nurses equated EBP with Healthcare Effectiveness Data and Information Set metrics and outcomes. For example, nursing staff verbalized awareness that certain diabetes metrics are monitored as a part of the business plan for the organization, but few of them were able to provide specific instances in which they used evidence to change nursing practice in daily care. Although there were trends toward significance on the EBPB and EBPI scores pre- and post-201 course, the small sample size (N = 10) may limit the generalizability of the findings to the larger population of RNs at both MTFs. A larger sample size may have resulted in a significant difference between EBPB and EBPI scores pre- and post-ebp 201. This assumption is supported by the collated responses (Table II) to the course feedback forms indicating a majority MILITARY MEDICINE, Vol. 178, September

7 TABLE IV. EBP Program Toolkit 1. A leadership Information Briefing that outlines the EBP program to garner support and authorization to proceed with implementation. 2. A Commander s Policy Letter that communicates the importance of EBP. 3. A digital screen shot of a balanced score card that shows where EBP can be embedded within the strategic management plan. 4. EBP 101 session slides with a cover letter detailing their use. 5. An EBP frequently asked questions (FAQ) flyer. 6. A digital copy of the Army Nurse Corps Mentorship Handbook An AMEDD Virtual Library flyer than can be used to educate staff and as an advertisement. 8. Five EBP nursing performance standards. 9. Digital screen shots and a description of how to create a computer shortcut to the AMEDD Virtual Library. of participants in the EBP 201 course achieved all eight course objectives, including the ability to mentor others as an EBP knowledge broker. RECOMMENDATIONS As a result of the lessons learned from implementing the EBP program, the authors developed the EBP toolkit described in Table IV. In addition, this toolkit is posted on an enterprise Web site for general use and is being used to educate new Army nursing leaders. Recommendations for further analysis and dissemination of the EBP program are the following: 1. Since most Army MTFs have implemented the PCTS, and EBP is one component of the PCTS, the EBP program should be incorporated into PCTS to facilitate dissemination of EBP to other Army outpatient MTFs. 2. This five strategy EBP program should be replicated at the other 32 freestanding Army outpatient facilities. Specifically, the EBP 101 and 201 courses should be used at all Army outpatient MTFs. 3. EBP facilitators are needed at all Army outpatient MTFs to coach, teach, and mentor nursing staff on using evidence to change nursing practice in daily care. 4. Other Department of Defence services (Air Force, Navy, and Coast Guard) and the Veteran s Administration may seek to replicate this program and evaluate the outcomes, applicability, and further refine the program. LIMITATIONS The limited sample size and short duration of the EBP program (6 months) may not have allowed for the full diffusion of the innovation into nursing practice as reflected by the nonsignificant results of the EBPI surveys. The EBP program should be studied longitudinally to ascertain its long-term effect on nurses engagement in EBP. The EBP 201 course should also be administered to a larger sample size to measure the effect of the course on nursing staff s belief about the value of EBP and their ability to implement and engage in evidence-based nursing practice. CONCLUSION Implementing a multidimensional EBP program has the potential to sustain practice change. 9 Adapting Greenhalgh et al 10 conceptual model (Fig. 1) provided a useful template for executing the EBP program and shows the integration of the five EBP implementation strategies to achieve sustainability. Establishing an organizational culture for EBP, enlisting the support of the entire leadership team in dedicating resources, involving end users, and including evidence based practice in performance reviews promoted the dissemination and application of EBP in two Army outpatient facilities. The EBP program helped to shape organizational and nursing culture. The program was successful in enhancing organizational culture and readiness for EBP as well as nursing staff s beliefs about the value of EBP and their ability to implement it. Nursing staff were provided the knowledge and tools that are requisite for using evidencebased nursing practice. An EBP program toolkit was developed to encourage the dissemination of the EBP program to other Army outpatient facilities. The toolkit is available by contacting the corresponding author. ACKNOWLEDGMENTS We thank Julie A. Thompson, Duke University School of Nursing, for her expertise in statistical analysis. This quality improvement project was fiscally supported by the leadership of McDonald Army Health Center, Fort Eustis, Virginia and Kenner Army Health Clinic, Fort Lee, Virginia. REFERENCES 1. Fineout-Overholt E, Levin RF, Melnyk BM: Strategies for advancing evidence-based practice in clinical settings. J N Y State Nurses Assoc 2004; 35(2): Smith JR, Donze A: Assessing environmental readiness: first steps in developing an evidence-based practice implementation culture. 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8 12. Stetler CB, Ritchie JA, Rycroft-Malone J, Schultz AA, Charns MP: Institutionalizing evidence-based practice: an organizational case study using a model of strategic change. Implement Sci 2009; 4(78): Melnyk B, Fineout-Overholt E, Mays MZ: The evidence-based practice beliefs and implementation scales: psychometric properties of two new instruments. Worldviews Evid Based Nurs 2008; 5(4): Army Nurse Corps: Army Nurse Corps Mentoring Program Handbook. Washington, DC, Department of the Army, Available at armynursecorps.amedd.army.mil/development/ancmentorshiphandbook Jan07.pdf; accessed June 25, Kennerly SM, Yap TL, Hemmings A, Becket G, Schafer JC, Borchers A: Development and psychometric testing of the Nursing Culture Assessment Tool. Clin Nurs Res 2012; 21(4): Varnell G, Haas B, Duke G, Hudson K: Effect of an educational intervention on attitudes toward and implementation of evidence-based practice. Worldviews Evid Based Nurs 2008; 5(4): Errata An error was made in Table 1 in the feature article Mentorship and Job Satisfaction Among Navy Family Physicians, by Saperstein, et al. published in Mil Med 2012; 177(8): Under the Age sub-heading, the n=151 correlates to <35 years old, but should correlate to ³35. The corrected table is below: TABLE I. Characteristics of Respondents (N = 186) Characteristic n % Gender Male Female Age <35 years ³35 years Residency Type Military Civilian 17 9 Years Since Residency < > Military Accession HPSP Other Rank O O O O Months Deployed Last 3 Years 0 months months months 8 4 The article Perceived Demands During Modern Military Operations published in Mil Med 2013; 178(7): 722 8, Listed the authors as: Sylvie M. Boermans, MSc; Wim Kamhuis, PhD; Roos Delahaij, PhD; J.E. (Hans) Korteling, PhD; Martin C. Euwema The list of authors should read: Sylvie M. Boermans, MSc; Wim Kamphuis PhD; Roos Delahaij, PhD; J.E. (Hans) Korteling, PhD; Martin C. Euwema MILITARY MEDICINE, Vol. 178, September