Grantham University Wk 11 Evidence Based Nursing Practice Discussion Questions

Available online at www.sciencedirect.com Applied Nursing Research 23 (2010) 1 www.elsevier.com/locate/apnr Editorial Connecting or disconnecting the dots between research and evidence-based practice What constitutes the evidence for evidence-based practice? Do we necessarily rely only on research and/or scientific evidence? Or are there other dimensions or types of evidence that are equally important or necessary for expert practice? I am constantly struck by the presentation in the literature equating research and evidence-based practice without the acknowledgment that there is a distinction. Often, evidencebased practice is described as research applied to practice. Further, the hierarchy of necessary evidence often refers to randomized controlled trials (RCTs) as the most valid form of evidence to weigh in the application of evidence to practice. Does the absence of RCTs in most of the areas in which we practice mean that we are without solid evidence on which to base our interventions? Evidence-based practice requires attention to more than science and research; it requires the expert judgment of the seasoned clinician as well as the knowledge generated from science. We all can judge expert clinicians based on the outcomes of their interventions but often find it difficult to describe their knowledge base or how they obtained their knowledge. Most of them have learned their art from practice. Yet, the expert clinician is more than someone with years of practice experience. The synthesis of knowledge from a range of sources is an absolute necessity for expert clinical practice. Further, 0897-1897/$ – see front matter © 2010 Published by Elsevier Inc. doi:10.1016/j.apnr.2009.10.001 evidence-based practice requires that conceptual understandings are embedded in the second core dimension of science, that of theory. I imagine that the equation of evidence-based practice and research is based on our efforts to simplify and to quantify, for what is observable and quantifiable is more often easier to understand. Objectifying and counting something seem to make it more real, especially to those of us used to the predominant scientific model. However, this merging of concepts may be suppressing the need to think more clearly about the nature of our clinical discipline. We have had evidence for some time that multiple ways of knowing provide a more complete picture of our interventions and their outcomes. The holistic nature of nursing deserves more than a one-sided perspective on knowing and more than scientific knowledge alone can teach us. Evidence-based practice thus demands attention to the broad evidence, to what we know as expert clinicians, and to what we know as scientists. We expect this integration of our beginning students in nursing as we teach them the art and science of nursing. We also should expect the integration within our own practice as scientists. Joyce J. Fitzpatrick (Editor) E-mail address: anrjournal@hotmail.com © Oncology Nursing Society. Unauthorized reproduction, in part or in whole, is strictly prohibited. For permission to photocopy, post online, reprint, adapt, or otherwise reuse any or all content from this article, e-mail pubpermissions@ons.org. To purchase high-quality reprints, e-mail reprints@ons.org. Evidence-Based Practice Carlton G. Brown, PhD, RN, AOCN®, FAAN—Associate Editor The Iowa Model of Evidence-Based Practice to Promote Quality Care: An Illustrated Example in Oncology Nursing Carlton G. Brown, PhD, RN, AOCN®, FAAN Evidence-based practice (EBP) improves the quality of patient care and helps control healthcare costs. Numerous EBP models exist to assist nurses and other healthcare providers to integrate best evidence into clinical practice. The Iowa Model of EvidenceBased Practice to Promote Quality Care is one model that should be considered. Using an actual clinical example, this article describes how the Iowa Model can be used effectively to implement an actual practice change at the unit or organizational level. Overview of Model (Melnyk et al., 2012). Numerous EBP models are available to help nurses organize and systematically track progress in implementing evidence into practice, including the Stetler Model of Research Utilization (Stetler, 2001), the Iowa Model of Evidence-Based Practice to Promote Quality Care (hereafter referred to as the Iowa Model) (Titler et al., 2001), and the Johns Hopkins Nursing Model (Newhouse, Dearholt, Poe, Pugh, & White, 2005). These models provide a step-by-step guide on how to take a clinical problem and match it with an intervention based on research to make an organizational or departmental change to practice. Using a model for EBP change also can assist nursing departments in better focusing their limited fiscal and personnel resources on critical EBP activities (Gawlinski & Rutledge, 2008). The current article will focus on one such model, the Iowa Model (Titler et al., 2001), as an example of how using a model can help focus on the process of implementing evidence-based changes (see Figure 1). The Iowa Model was selected because nurses find it intuitively understandable and it has been used in numerous academic settings and healthcare institutions (Gawlinski & Rutledge, 2008). The Iowa Model can help nurses and other healthcare providers translate research findings into clinical practice while improving outcomes for patients. The first step in the Iowa Model is to identify either a problem-focused trigger or a knowledge-focused trigger where an EBP change might be warranted. Problemfocused triggers are those problems that derive from risk management data, financial data, or the identification of a clinical problem (e.g., patient falls). Knowledgefocused triggers are those that come forward when new research findings are presented or when new practice guidelines are warranted. The next step in the Iowa Model is for the nurse or team to determine whether the problem at hand is a priority for the organization, department, or unit in which they work. Those problems that may have higher volume or higher costs associated likely will have higher priority from the organization. Organizational buy-in is crucial when working on EBP issues, so knowing the prioritization of the problem is important. Once the priority has been determined, the next step is to form a team consisting of members that will help develop, evaluate, and implement the EBP change. The composition of the team will be determined by the problem at hand. Titler et al. (2001) pointed out that the team should include interested interdisciplinary stakeholders. This step is important and should include team players outside of those from nursing. Once a team has been formed, the next step is to gather and critique pertinent research related to the desired practice change. The most important portion of this step is to form a good question (using the PICOT method [Guyatt, Drummond, Clinical Journal of Oncology Nursing • Volume 18, Number 2 • Evidence-Based Practice 157 Carlton G. Brown, PhD, RN, AOCN®, FAAN, is the director of Professional Services at the Oregon Nurses Association in Tualatin. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Brown can be reached at cgenebrown@gmail.com, with copy to editor at CJONEditor@ons.org. Key words: evidence-based practice; research; decision making Digital Object Identifier: 10.1188/14.CJON.157-159 N urses understand that evidencebased practice (EBP) improves the quality of patient outcomes while controlling the cost of healthcare (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). But even in the year 2014, barriers and roadblocks exist to implementing EBP at the bedside or chair side. The Institute of Medicine estimated that it takes more than 17 years to implement a research finding into clinical practice (Institute of Medicine, 2001). Although research may exist that should be translated into practice, the time it takes to deliver these research-based interventions to patients takes too long. In their study of 1,054 RNs, Melnyk et al. (2012) discovered that although nurses value EBP, they required education, access to information, and time to implement EBP into daily practice. Nurses and other healthcare providers want their practice based in evidence, but they also acknowledge the barriers of lack of education and time to actually implement and use EBP. EBP is a problem-solving approach to clinical decision making that integrates the best evidence from well-designed studies with a clinician’s expertise along with patients’ preferences and values Meade, & Cook, 2008]) and then conduct a literature search for actual research studies that pertain to the question at hand. This is an excellent time to enlist a medical librarian who can help search for and retrieve studies to aid in choosing an Problem-Focused Triggers 1. Risk management data 2. Process improvement data 3. Internal/external benchmarking data 4. Financial data 5. Identification of clinical problem Knowledge-Focused Triggers 1. New research or other literature 2. National agencies or organizational standards and guidelines 3. Philosophies of care 4. Questions from institutional standards committee Consider other triggers Is this topic a priority for the organization? No Yes Form a team Assemble relevant research and related literature Critique and synthesize research for use in practice Is there a sufficient research base? Yes Base Practice on Other Types of Evidence 1. Case reports 2. Expert opinion 3. Scientific principles 4. Theory Pilot the Change in Practice 1. Select outcomes to be achieved 2. Collect baseline data 3. Design evidence-based practice (EBP) guideline(s) 4. Implement EBP on pilot units 5. Evaluate the process and outcomes 6. Modify the practice guidelines Continue to evaluate quality of care and new knowledge No No Is change appropriate for adoption in practice? Disseminate results Yes Conduct research Institute the change in practice Monitor and Analyze Structure, Process, and Outcome Data • Environment • Staff • Cost • Patient and family FIGURE 1. The Iowa Model of Evidence-Based Practice to Promote Quality Care Note. Figure courtesy of Marita Titler. Used with permission. 158 intervention or answer to the problem or knowledge-focused question. The next step is that the team must critique the available studies to determine whether the study with the tested intervention is scientifically sound. Not every research article published in a professional journal has appropriate scientific merit. Sometimes articles have a small sample size or perhaps use a tool lacking reliability or validity, so critiquing every article prior to considering the results of that study for implementation into a practice change is important. Advanced practice nurses are ideal members of the team to assist with the critique of respective research studies (Titler et al., 2001). Titler et al. (2001) also suggested pairing novice team players with members who are experts or more experienced in critiquing research. At this juncture, the team needs to decide whether sufficient research exists to implement a practice change. Titler et al. (2001) suggested the following criteria be considered when determining whether research can be implemented into practice: (a) consistent findings exist from numerous studies to support the change, (b) the type and quality of the studies, (c) the clinical relevance of the findings, (d) the number of studies with similar sample characteristics, (e) the feasibility of the findings in practice, and (f) the risk-benefit ratio. If a majority of the criteria can be met, the team should then plan to implement the intervention in a pilot practice change. If adequate research does not exist, an actual research study might be conducted. The next step would be to implement the intervention into a pilot practice change. Notice here that the team would not conduct a full practice change for the entire organization, but rather would implement a pilot change in one or two smaller practice areas first; the team needs to ensure the change is feasible and will result in improved outcomes before full-scale implementation. If the intervention is successful in pilot implementation, it can be converted to an organization practice change. Even after a practice change has been implemented, the team should continue to evaluate the practice change, watching for any April 2014 • Volume 18, Number 2 • Clinical Journal of Oncology Nursing deviation in practice or a decrease in the outcomes. An Illustrated Example A clinical example will now be used to illustrate how a group of nurses and other healthcare providers could use the Iowa Model to make a change to clinical practice and improve overall patient outcomes. A group of oncology nurses working on an inpatient stem cell transplantation unit were particularly concerned about the high level of patient falls, some of which resulted in patient injury. The group, led by an advanced practice nurse, decided to use the Iowa Model to help guide the process of finding a potential practice change. The team learned that patient falls with injury were an overall concern for the organizational, given that they not only resulted in poorer patient outcomes but also had significant financial costs for the organization. The group of oncology nurses formed a falls prevention team and invited interested interdisciplinary members, including physicians, nurses, physical therapist, occupational therapists, and other hospital employees, to join. The team then asked the medical librarian to help them collect relevant randomized, controlled trials and other studies, and the team critiqued those studies for scientific merit. The team came across numerous studies that supported patients wearing bright-colored, non-skid socks when at risk for falls. The socks were implemented as a practice change to two inpatient units as a pilot. During the four- month pilot, the team documented a decrease in patient falls on units where the patients were wearing the bright-colored, non-skid socks. The team then decided to implement the practice change in the entire organization and are continuing to monitor monthly patient fall levels. Conclusion Nurses want to implement interventions in their practice based on the highest levels of evidence. However, nurses also have noted that they need time and more education to translate current evidence into practice. The use of an EBP model, such as the Iowa Model (Titler et al., 2001), can help nurses organize the practice change and provide them with a step-bystep process on how make the change for a unit or organization. References Gawlinski, A., & Rutledge, D. (2008). Selecting a model for evidence-based practice changes: A practical approach. AACN Advanced Critical Care, 19, 291–300. doi:10.1097/01.AACN.0000330380.41766 .63 Guyatt, G., Drummond, R., Meade, M., & Cook, D. (2008). Users’ guides to the medical literature: A manual for evidencebased clinical practice (2nd ed.). New York, NY: American Medical Association. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century (pp. 8–25). Washington, DC: National Academies Press. Melnyk, B.M., Fineout-Overholt, E., GallagherFord, L., & Kaplan, L. (2012). The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. Journal of Nursing Administration, 42, 410–417. doi:10.1097/ NNA.0b013e3182664e0a Newhouse, R., Dearholt, S., Poe, S., Pugh, L.C., & White, K.M. (2005). Evidence-based practice: A practical approach to implementation. Journal of Nursing Administration, 35, 35–40. doi:10.1097/00005110 -200501000-00013 Stetler, C.B. (2001). Updating the Stetler Model of research utilization to facilitate evidence-based practice. Nursing Outlook, 49, 272–279. doi:10.1067/mno.2001 .120517 Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., . . . Goode, C.J. (2001). The Iowa Model of evidencebased practice to promote quality care. Critical Care Nursing Clinics of North America, 13, 497–509. Do You Have an Interesting Topic to Share? Clinical Journal of Oncology Nursing • Volume 18, Number 2 • Evidence-Based Practice 159 Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Nursing Research January/February 2010 Vol 59, No 1S, S11–S21 Collaborating Across Services to Advance Evidence-Based Nursing Practice Deborah J. Kenny 4 Maggie L. Richard b Background: Military medical treatment facilities offer a unique environment in which to develop a culture of evidence-based practice (EBP). Distinctive issues arise in the context of changed patient care demographics because of a war-injured population. These issues offer an opportunity to enhance the quality of care through the use and adaptation of research findings in this special nursing environment. In addition, the colocation of two military medical centers offers the prospect of collaborative efforts to create a regional culture for nursing EBP. b Objectives: The purposes of this study were to describe the processes of a collaborative project to train nurses in EBP and to share resources in developing and implementing evidence-based clinical nursing guidelines in two large military medical centers in the Northeastern United States and to discuss the collective efforts of nurse researchers, leadership, advanced practice nurses, and staff nurses in each hospital to facilitate the EBP process. b Methods: A description of the organizational structure and the climate for EBP of each facility is provided followed by discussion of training efforts and the inculcation of an organizational culture for EBP. b Results: Contextual barriers and facilitators were encountered throughout the project. The two nurse researchers leading the projects were able to overcome the barriers and capitalize on opportunities to promote EBP. Three evidencebased clinical practice guidelines were developed at each facility and are currently in various stages of implementation. b Discussion: Despite the barriers, EBP continues to be at the forefront of military nursing practice in the U.S. National Capital Region. Clear communication and regular meetings were essential to the success of the collaborative project within and between the two military hospitals. Militaryspecific barriers to EBP included high team attrition and turnover because of the war mission and the usual high staff turnover at military hospitals. Military facilitators included a common mission of providing high-quality care for war-injured service members. Lessons learned from this project can be generalized to civilian facilities. b Key Words: evidence-based practice & practice guideline & quality assessment 4 Xochitl Ceniceros 4 Kelli Blaize A s in the civilian healthcare community, in military medical treatment facilities (MTFs), attention has been focused on the importance of using scientific evidence to guide nursing practice and improve patient outcomes in both fixed facilities (Weisgram & Raymond, 2008) and in environments related to wartime activities such as evacuation aircraft (Schmelz, Bridges, Duong, & Ley, 2003) and combat support hospitals in war zones (D. Hopkins-Chadwick, personal communication, 2007). Since the early 1990s, the Veteran’s Administration has partnered with the Department of Defense (DoD) to develop clinical practice guidelines based on research evidence (U.S. Department of Veterans Affairs, 2006). The importance of creating a culture that uses and values evidence in military healthcare practice is recognized as MTFs make efforts to provide the highest quality of care to war-injured service members and beneficiaries. The military healthcare system offers a unique environment in which to develop clinical practice. During peacetime, the mission is much the same as that of any civilian facility. Care is centered on active duty military personnel (soldiers, sailors, and airmen) but also extends to their eligible family members as well as to retired military personnel and their spouses. The demographics of patients and their diseases are much the same as those of patients in civilian hospitals (Columbo, Mount, & Popa, 2008; Cooper & Linde-Zwirble, 2004). However, during wartime, the mission of an MTF changes to focus on the injured war fighter. Families and other beneficiaries may be cared for in the military facility as resources permit or may be referred to civilian facilities to receive care. During Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF), the patient demographics of the two medical centers involved in the project described in this Deborah J. Kenny, LTC, AN, USA, PhD, RN, is Executive Director, TriService Nursing Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Maggie L. Richard, CAPT, USN, NC, PhD, RNC, is Director, Navy Human Research Protection Program, Bureau of Medicine & Surgery, Washington, DC. Xochitl Ceniceros, MS, RN, is Research Assistant, Department of Orthopedic Surgery, National Naval Medical Center, Bethesda, Maryland. Kelli Blaize, BS, MA, is Program Manager, Nursing Research Services Department, National Naval Medical Center, Bethesda, Maryland. Nursing Research January/February 2010 Vol 59, No 1S Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. S11 S12 Collaborating Across Services presentation changed from older beneficiaries with diseases typically seen in the surrounding civilian facilities (e.g., heart disease, pulmonary disease, and gastrointestinal diseases) to younger patients with diseases and polytrauma inherent to the war scenario in Southern Asia (Columbo et al., Mount, & Popa, 2008; Kenny & Hull, 2008). This unique, younger patient population presented some challenges to usual practices and necessitated changes to standard operating procedures. Every attempt was made to utilize available evidence when changes were necessary. However, as some care of the war-injured personnel warranted innovation, practices changed even as research was ongoing to provide evidence for some of these changes. For example, the use of wound vacuum-assisted closure devices and the employment of continuous peripheral nerve blocks have become standard of care for service members with large wounds or amputations (Leininger, Rasmussen, Smith, Jenkins, & Coppola, 2006; Malchow & Black, 2008). Because of these innovations and the drastically decreased length of time of evacuation from the battlefield to definitive care in fixed U.S. facilities, the survival rate of injured soldiers has increased from 75% to 85% in previous wars to around 90% in the wars in Afghanistan and Iraq. Conversely, however, this means that more service members who have more complex and severe wounds are reaching stateside hospitals for care (Grathwohl & Venticinque, 2008). Scope of the Project This project was one component of a larger evidence-based practice (EBP) grant initiated through the TriService Nursing Research Program (TSNRP). This large grant provided funding for region-specific military medical centers to develop their own programs for EBP based on some of the developing problem-focused triggers as a result of caring for injured soldiers. A definition of EBP applicable to this project was developed through interservice meetings sponsored by the TSNRP. The adopted definition is as follows: Evidence-Based Nursing Practice is the appraisal and application of research and other sources of valid, applicable knowledge to provide guidelines for improvement of patient outcomes, quality nursing care, and to support nursing policy decisions. Acceptable sources of evidence can be found on many levels ranging from randomized controlled trials to expert opinion; and the sources are graded on many levels based on the strength of its science and appropriateness for implementation. Use of evidence in nursing practice must be evaluated on the following: 1) validity, 2) appropriateness (patient, institutional & clinical practice), and 3) feasibility for implementation into practice or as the basis of policy/ procedure decisions (TSNRP, 2004, p. 1). Because the U.S. National Capital Region contains two military medical centers in proximity, efforts were combined to collaborate in the enculturation of EBP and the development of EBP programs at each medical center. Ultimately, three guidelines were to be developed at each of the medical centers then exchanged and adapted accordingly at the other medical center. As they were developed, Nursing Research January/February 2010 Vol 59, No 1S they were made available also for other use at other MTFs across the military as appropriate. Subsequent to the initiation of this project, decisions were made by the DoD to combine the two medical centers and realign care at other MTFs in the National Capital Region as part of the base realignment and closure process by 2011. The processes and guidelines developed as a part of this project are expected to form the basis for evidence-based nursing care for the new National Capital Region healthcare system. This project was conceived in 2002, before the start of OIF/OEF, but the bulk of the project was carried out after the wars began, and it was influenced heavily by those events. The project involved both performance improvement and the use of research methods for the development, implementation, and evaluation of clinical guidelines, as well as the collection of data from nursing personnel. During the preimplementation and postimplementation phases of EBP, the research component evaluated research utilization, the work environment, and innovativeness. Results of these surveys will be published elsewhere and will not be discussed in this article. The specific aims for the performance improvement phase of this EBP project were 1. to train a core of nursing personnel at two northeastern medical centers in the development and implementation of evidence-based nursing practice protocols, 2. to develop and implement three different evidencebased nursing practice guidelines at each site, 3. to have personnel who were trained in EBP at the two medical centers assume a consultative role in smaller MTFs in the development and implementation of evidence-based nursing practice protocols, and 4. to gather performance improvement metrics measuring implementation and sustainment of each EBP protocol. In this presentation, the collaborative effort between the two medical centers, barriers encountered, and methods used to facilitate EBP will be described. Findings from the implementation of one of the guidelines (Aim 4) are presented in the Kenny and Goodman article in this supplement. Structure and Description of the National Capital Region and its Facilities Army Medical Center One of two MTFs was a large U.S. Army medical center in Washington, DC, a 260-bed facility with an expansion capacity to 500+ beds as necessary. It has a daily inpatient census of approximately 150Y175, of which approximately 20%–25% is war injured. Responsible for about 25% of the Army’s total patient load, the hospital and various clinics handle approximately 600,000 outpatient visits per year. The MTF receives patients from across the United States and Europe for specialty care. The medical center is part of a regional healthcare system that has the largest graduate medical education program in the Army and is home to 65 residency, fellowship, and internship programs. Approximately 1150 nursing personnel work in 16 inpatient wards and various outpatient clinics throughout the facility (Walter Reed Army Medical Center, Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Nursing Research January/February 2010 Vol 59, No 1S 2008). These nursing personnel consist of active duty Army soldiers, DoD civilians, reserve soldiers who temporarily replace active duty nurses serving in the war zone, and nurses hired under contracts to assist with personnel shortfalls. The staff includes registered nurses, licensed practical nurses, and nursing assistants. Navy Medical Center The Navy medical center is a unique military medical complex located in Bethesda, Maryland, providing high quality care to over 200,000 active duty personnel, retirees, and family members while keeping the fighting forces fit. It has a capacity of 158 adult beds and 25 neonatal isolettes with the capacity to expand to 621 beds and consists of 9 inpatient units and 46 outpatient clinics. The daily inpatient census is approximately 120, with about 15%–20% of the inpatient population being war-injured service members. The clinics treat more than 1500 patients daily. Approximately 600 nursing personnel work at the medical center, which include registered nurses, licensed practical nurses, and nursing assistants. As in the Army medical center, these personnel consist of active duty Navy sailors, DoD civilians, Navy reservists, and contract agency nurses. This MTF is a referral center for military medical facilities worldwide and provides state-of-the-art medical treatment for service members representative of the Armed Forces and other beneficiaries. The services provided are supported by an in-depth exposure to all major medicine subspecialties and by a faculty specifically chosen for their teaching interest and skill. Currently, there are 16 graduate medical educational programs at the facility (National Naval Medical Center, n.d.). Both facilities are strong advocates for nursing research and the use of research findings in clinical nursing practice. They have independent nursing research departments led by active duty nurse scientists. These doctorally prepared nurses are funded researchers and provide senior nurse executives with data regarding care practices and staffing effectiveness. They also assist with performance improvement initiatives. These nurse researchers are in the perfect position to champion EBP initiatives and provide strategies for sustaining EBP. Methods Before beginning the development phase of the EBP project at both medical centers, a 3-day training seminar was set up to (a) introduce EBP to nursing leadership (this was a half-day educational program) and (b) train a core of advanced practice nurses in the process of developing and implementing evidence-based guidelines (a 22-day seminar). Internationally known EBP experts Dr. Marita Titler and Laura Cullen (University of Iowa, Iowa City) conducted the training. Lecture, discussion, and small-group work were used in the seminar to educate the nurses in a structured methodology for developing and implementing EBP guidelines. It was during the small group discussion that the topics for the guidelines at the two medical centers were conceived, based on problem-focused triggers in patient care areas. The nursing leaders at both medical centers were excited about the implementation of EBP and expressed support for the project. Product line managers and section Collaborating Across Services S13 supervisors allowed 25 master’s-prepared advanced practice nurses (12 from the Navy medical center and 13 from the Army medical center) to attend the training and to engage in the development of guidelines. Middle managers supported the project by giving ward nurses administrative time to work on the necessary literature reviews, data collection, and guideline development and to provide staff training for implementing the developed guidelines. Nursing practice councils at both medical centers became involved in supporting implementation of the guidelines by providing suggestions for developing the topic areas and offering ideas to speed implementation. In contrast to these encouraging developments, there were several important factors that delayed implementation. Perhaps most important, the war and the increased workload inherent to caring for ever-changing numbers of service members who are severely injured and sick necessitated continual readjustment of priorities. In addition, staff turnover was very high due to deployment of nursing personnel to the war zone, temporary reserve replacements, and the increased use of contract staff. EBP, although still considered very important, was often trumped by patient care issues. The leadership continued to support EBP, but it was necessary to keep a close eye on the progress of guideline development and a high level of persistence to maintain the project’s momentum. There was a continued need to educate new leadership and EBP team members about the project and its importance as members of the EBP teams changed when staff were deployed or changed duty stations and new nursing staff came in from other hospitals. Communication The projects were led by doctorally prepared nurse researchers assigned to each medical center. Initial communication between the two nurse researchers was facilitated by the TSNRP. The researcher from the Army facility (Kenny) had already submitted a project proposal for this endeavor, and the Navy researcher (Richard) adapted it for use at the Navy facility. Once the proposals were accepted by the TSNRP, the researchers submitted them to their individual institutional review boards for approval. The main thrust of the project was performance improvement, but because part of the intent of developing the guidelines was to share across military facilities and also because it included surveys to determine uptake of EBP, institutional review board review was necessary. Approval was obtained from the Army medical center in December 2003 and from the Navy medical center in April 2004. The clinical questions addressed for the Army medical center were related to prevention and care of pressure ulcers, care of the patient with enteral feedings, and risk assessment for deep vein thrombosis and pulmonary embolus. Addressed at the Navy medical center were clinical questions related to falls prevention, pain management, and thermoregulation of the neonate. Although each facility was developing and implementing three different guidelines individually, the two researchers held face-to-face meetings on a regular basis and further communicated through frequent e-mails and telephone calls. Regular teleconferences were held with Dr. Titler Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. S14 Collaborating Across Services Nursing Research January/February 2010 Vol 59, No 1S FIGURE 1. Evidence-based practice timeline: U.S. Army facility (continued). Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Nursing Research January/February 2010 Vol 59, No 1S Collaborating Across Services S15 FIGURE 1. (continued) to discuss progress with the prescribed EBP processes. Through this regular communication, the researchers were able to brainstorm ideas, solve problems, and make recom- mendations to enhance the projects and sustain progress. They also met regularly to share successes and challenges, collaborate on writing the required reports, and prepare Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. S16 Collaborating Across Services Nursing Research January/February 2010 Vol 59, No 1S presentations to disseminate the project across both military and civilian nursing communities. The organizational structure at the medical centers was not the same, and different strategies were needed at each facility for the successful development Strategies and implementation of guidelines. The The primary facilitative strategy for the Navy medical center employed incenproject was funding. The TSNRP suptives to sustain nursing participation Funding was probably the ported hiring of two master’s-prepared that involved providing input to pernurses as project directors to perform formance evaluations and support for single most important various tasks associated with the EBP and funding of presentations at scientific facilitator for the project. projects. At the Army medical center, the venues. Interacting with nursing staff project director was a 0.5 full-time equivsupervisors and the senior nurse exalent who searched the literature for all ecutive resulted in nurses having fewer three guidelines, coordinated team meetscheduling conflicts, which facilitated parings, distributed materials, assisted with ticipation in literature reviews and meetpreimplementation data collection, and ings. Last, planning standard meeting maintained the databases. The Navy times during lunch hours resulted in conqqq medical center used a 1.0 full-time equivtinuous nursing attendance throughout alent project director who supported meeting tasks, literature the process. These strategies provided a lifeline for EBP and synthesis, workshop development, coordination of data for proved to be the most critical factors for implementation and meetings, and interaction and follow-up with unit nurses. sustainability. FIGURE 2. Evidence-based practice timeline: U.S. Navy facility (continued). Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Nursing Research January/February 2010 Vol 59, No 1S At the Army medical center, attrition of the team became a problem with the first guideline developed, partially due to the length of time taken to review and synthesize the literature (approximately 6 months before guideline development). M. Titler (personal communication, 2002) had recommended that the time for developing and implementing EBP guidelines, which includes literature review and synthesis, can take 12Y18 months depending on the topic, contextual factors, and breadth or number of units involved in the implementation of the practices. Although realistic, this proved to be too long a timeframe mainly because of the high staff turnover in the hospital. For the second and third guidelines, the time frame for development and beginning implementation was shortened to 4 months. The nurse researcher negotiated with the deputy Collaborating Across Services S17 commander for nursing and the head nurses for team members to have 1 day per month for guideline development for a 4-month period rather than 2 hours per week for several more months. It was easier to schedule a team member for an entire day for administrative time than to try to cover that person’s patient care responsibilities for 2 hours on a weekly basis. In addition, team participants were given continuing education credits for their participation. This resulted in concentrated team efforts to work on the guidelines with ample time between meetings for individual work. This shortened timeframe decreased attrition of the teams and delivered a product to nursing management in a more timely fashion. An interdisciplinary, evidence-based approach at each of the facilities augmented communication between different FIGURE 2. (continued) Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. S18 Collaborating Across Services Nursing Research January/February 2010 Vol 59, No 1S healthcare providers whose goal was to enhance the quality of care for the patients. Transfer of knowledge among the disciplines also enhanced collegiality in problem solving and increased the buy-in for the practice guidelines. This resulted in increased interdisciplinary communication and the development of a program at both facilities where the goal was to improve patient care. The timelines for development and implementation of three guidelines each at both medical centers are illustrated in Figures 1 and 2. advancing EBP and improving patient outcomes at both medical centers. The nurses recognize the need for support from their managers and leaders, but they believe that time and the skills The evidence-based needed to evaluate literature are barriers. They are willing to be mentored protocols developed by advanced practice nurses. In addiwithin the context of this tion, nurse researchers are in a perfect position to champion such change and project have been shared to assist with finding, reviewing, and throughout the three interpreting the literature. Both past and military services. present nurse researchers at the medical centers have developed a rapport with the nurses practicing at the bedside and continue to encourage them to bring Barriers practice issues to the table for examinaqqq Change is not always easy, and this projtion of the evidence and potential changes ect has been no exception. Throughout for improvement. Nurse researchers at the course of the implementation and sustainability phases, it both facilities plan to submit future grant proposals to was clear that contextual factors such as increased patient advance and sustain EBP in the National Capital Region acuity due to injured OIF/OEF patients, high patient census, through projects examining medication errors and blood limited time, staffing shortages due to deployment, and retransfusions. assignment (attrition and turnover) hindered the ability of Several factors illustrate the benefits of collaboration team members to be present at EBP team meetings. Many between the two premier healthcare facilities that are the times, members reported to the wards before going to the subject of this report. The first and most important benefit team meetings, only to be told that the patient care mission was the funding opportunity that resulted in (a) joint EBP took priority over EBP for that day. Because the team training workshops conducted by experts in the field, members were excited about and motivated to continue (b) the sharing of support staff critical to synthesis and their participation in the EBP projects, they agreed to atcritiquing of the literature, (c) the exchange of lessons tend meetings on prescheduled days off or when they were learned, and (d) the strategies for ensuring sustainability of not on a shift. the EBP program. The funding resulted in a core of 25 adStaff nurses were hesitant to make changes in their pracvanced practice nurses who were trained in EBP methods. tice, especially changes that might add to their already high Other benefits are related to the ongoing transfer of knowlworkloads. The nurse researchers were cognizant of these edge and experience between the doctorally prepared staff nurses’ time limitations and designed the evidencenurses and nursing staff trained in the implementation based changes to be as close as possible to what the nurses and diffusion of EBP. were doing already. This tactic is in accordance with Rogers’ An additional benefit is that transfer of knowledge bemodel of diffusion of innovations that adoption is more tween the medical centers prevents the redundancy of reinlikely to occur with innovations that are close to current venting the wheel and the ineffective use of resources to practice (Rogers, 1995). On the other hand, some evidenceanswer clinical questions that have been addressed adebased changes were quite different from what nurses were quately at other MTFs. Guidelines for falls and wound care already doing. For example, one guideline required an added have been shared, and communication between medical centool for assessing the risk of deep vein thrombosis in the ters continues regarding these and other guidelines to be already time-intensive admission package. Adding the tool developed. meant extra time for documentation, and, at first, the nurses The nurse researchers at both medical centers have were slow to make the change. However, when they saw successfully tapped into the pulse of nursing care and guided tangible benefits, those who adopted the change first the EBP process from generation of the clinical question to the convinced the slower adopters of the benefits of the new ongoing evaluation of the fully implemented projects. The tool, and the practice change was implemented throughout multidisciplinary EBP workgroups, funding allocation, and the hospital. nursing support were critical factors for implementing guidelines that improve both patient outcomes and other outcomes that are organizationally relevant. The EBP initiative at Results both facilities has resulted in nurses being inherently aware The EBP projects in the National Capital Region can be of the power they have to create, expand, and apply evidence considered a success; the goal of having three evidencethat informs their practice, leading to improved patient outbased guidelines developed and implemented (the third is comes. Additional benefits include establishment of a cadre still in the process of implementation) at each of the two of trained nurses competent to answer critical clinical, reMTFs was achieved through the collaborative efforts of search, and administrative questions related to the specific personnel from both sites. Regardless of the many limiEBP projects. The synergy that came from this collaboration tations of this project, clear progress has been made in resulted in achievement of valued outcomes, emergence of Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Nursing Research January/February 2010 Vol 59, No 1S Collaborating Across Services S19 new EBP topics, and creation of an enas well as assistance with the database vironment that sustains EBP. to maintain the project’s momentum. The implementation process and It was also possible to purchase incensustainment initiatives at both medical tive tokens for staff and tangible, visicenters have created an environment ble training aids such as unit posters where EBP is thriving and reshaping and training displays for implementaOrganizational context the paradigm of the importance of evition of guidelines. must be considered when dence for improving practice and paHaving doctorally prepared and tient outcomes. Historical relationships EBP-trained nurse project coordinators developing and and current successes are a trajectory at each facility to champion the project implementing an for future EBP topics, collaboration, and provide ongoing training for staff and implementation of research. Nursand team members was integral to the EBP program. ing practice councils meet monthly to success of the project. It was important discuss clinically relevant questions and for champions to be highly visible to the evaluate other EBP guidelines at these staff during the project to allow for staff institutions. At the Navy medical ceninput and to communicate the benefits ter, an EBP council was implemented in and importance of using evidence conqqq 2007 and has resulted in implementatinually to enhance their care. The fact tion of strategies for other key clinical issues such as rethat the champions were not part of the nurses’ line auduction of errors and standardized processes for blood thority facilitated communication regarding patient care administration throughout the hospital. A second benefit of issues. Staff members recognized the champions as symcollaboration in this project has been the ability to dispathetic to their needs and were more open to practice seminate the success through local, regional, national, and suggestions. Visibility of the doctorally prepared nurses on international nursing conferences via publications, posters, nurses’ work units did much to change the perception that and podium presentations. For example, the project was the doctorally prepared nurses are so far removed from presented in July 2005 at the 16th Annual Sigma Theta patient care and so unaware of the factors influencing Tau International Research Congress, Waikoloa, HI, and nursing practice that they have little in the way of practical in October 2007 at the Maryland Nurses Association Ansuggestions to offer busy nurses at the bedside. nual Conference, Baltimore, MD. Throughout the course of implementation and sustainability phases, it was clear that contextual factors such as Assisting Other Nurses in the EBP Process increased average patient acuity because of the need to care To achieve Aim 3, the nurse researchers from both facilities for OIF/OEF patients with severe injury, higher-thandeveloped an EBP educational workshop to train nurses at average patient census, limited time, and staffing shortages another large Navy medical center in Virginia. The workdue to deployment and reassignment (attrition and turnover) shop consisted of 2 days of training, with one half-day were constraints. The presence of these factors inhibited the session geared toward an overview of the EBP initiative at ward nurses’ ability to review the literature and implement the National Capital Region facilities and the process of key elements of the EBP process. At the Army medical cenEBP. The other 12 days was dedicated to in-depth training ter, the timeframe between guideline development and final of teams of nurses who would be working with teams of departmental approval was prolonged because of leadership personnel on preidentified projects at the medical center. turnover and the necessity to reorient four deputy After the training, regular communication occurred to ensure commanders for nursing during the timeframe of the project, that progress was being made and to offer help as needed. resulting in delays implementing the guidelines at the ward Further educational workshops have been conducted at levels. two Army facilities, and more are planned. In addition, a However, despite frequent turnover, the leadership and series of 17 EBP articles was written for the monthly Army staff at both facilities were committed to the projects and, Nurse Corps Newsletter to educate nurses in the process of through the help of the nurse researchers, were able to EBP. overcome many of the contextual barriers. The program successfully created a new culture for evidence-based nursing practice in the National Capital Region; however, the Discussion contextual barriers remain, and the effects were temporary. Despite the contextual barriers, this collaborative project At the U.S. Army facility, nursing leadership is struggling was considered a success at both medical centers. Six colcurrently to maintain the culture for EBP as other issuesV lective evidence-based guidelines were implemented effecsuch as nurse burnout and the continued stress associated tively. Since then, the nursing practice councils at both have with prolonged caring for injured soldiersVhave surfaced as examined problem-focused practice triggers and used evia more serious issue needing time and attention (S. Annicelli, dence to change processes related to blood transfusions and personal communication, 2009). medication administration. Several lessons have been learned from this EBP colFuture Directions laboration. Funding was probably the single most imporThere is a need within the military healthcare system for tant facilitator for the project. Through the funding, it was nursing care protocols to be based on the best evidence possible to hire project directors to provide logistic help available. Whether in a civilian or military environment, Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. S20 Collaborating Across Services the ability to evaluate research findings and incorporate them into practice is an important skill for the clinical nurse. The evidence-based protocols developed within the context of this project have been shared throughout the three military services to enhance the quality of patient care and improve outcomes of military healthcare beneficiaries. As efforts to consolidate the healthcare system continue across the military, it becomes imperative for nurses to collaborate across facilities to develop and implement practice guidelines based on the best evidence available. Currently, Army, Navy and Air Force nursing personnel in the National Capital Region are jointly involved in an EBP Research Council that serves as a sustainable venue for the development of clinical questions that will guide EBP and research for TriService facilities in the future. Periodic meetings are aimed at common evidence-based processes to be developed and adapted at the various facilities throughout the region. Military organizations provide opportunity for future organizational research examining the organizational diffusion of innovations, but they could also make distinct practice contributions to the nursing knowledge base in general. There are inherent barriers to the uptake of innovative practices in any organization, and the military facilities provide a unique perspective that requires different strategies to successfully initiate and sustain evidence-based nursing practice. The higher turnover of staff, a different set of patient demographics, and patient missions are often radically different from those seen in civilian practice. This collaborative EBP project between two northeastern MTFs has provided a template for the sustained ability to evaluate and translate evidence to practice throughout the respective institutions. An interdisciplinary evidence-based approach at both facilities resulted in the development of programs that reduced harm for patients receiving care and increased the quality of their care. Dopson (2007) described the complexity of any organization and the need to holistically look at all levels of the organization in concert with the processes of knowledge translation. Organizational context must be considered when developing and implementing an EBP program. Because the context changes according to circumstances (in this case, OIF/OEF), it is important to ensure ongoing evaluation of factors that impact implementation and diffusion. Failure to account for changing contextual factors can affect the momentum and sustainability of EBP programs negatively not just in military facilities but also in civilian organizations. Because of the high rate of staff turnover, continual training and refreshers by the researchers and team members were essential to sustain the momentum and culture of EBP in both facilities. Summary This article describes the processes of an EBP project carried out in two military hospitals and the collaborative efforts between the two nurse researchers at both. Although these facilities had militarily unique barriers and facilitators, the nurse researchers also faced many of the same barriers and facilitators described in the general EBP literature (Funk, Tornquist, & Champagne, 1995; Green & Nursing Research January/February 2010 Vol 59, No 1S Ruff, 2005; Herr et al., 2004; Hutchinson and Johnston, 2006). What this presentation adds to the larger body of knowledge is that a unique context such as that found within and even between military healthcare facilities requires different strategies and approaches to secure success in the enculturation and valuing of putting evidence into practice. q Accepted for publication April 30, 2009. This project was funded by an award from the TriService Nursing Research Program, BResearch to Practice,[ Grant N03-P18 by CAPT Patricia W. Kelley, principal investigator. The Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814-4799 is the awarding and administering office. The views and opinions expressed in this article are solely those of the authors and do not reflect the policy or position of the Department of the Army, Department of the Navy, Department of Defense, or the U.S. Government. This project was sponsored by the TriService Nursing Research Program, Uniformed Services University of the Health Sciences; however, the information or content and conclusions do not necessarily represent the official position or policy of nor should any official endorsement be inferred by the TriService Nursing Research Program, Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. Corresponding author: Deborah J. Kenny, LTC, AN, USA, PhD, RN, 350 S. Clinton St. Apt 1D, Denver, CO 80247 (e-mail: deb.kenny@ us.army.mil). References Columbo, C. J., Mount, C. A., & Popa, C. A. (2008). Critical care medicine at Walter Reed Army Medical Center in support of the global war on terrorism. Critical Care Medicine, 36(7 Suppl.), S388YS394. Cooper, L. M., & Linde-Zwirble, W. T. (2004). Medical intensive care unit use: Analysis of incidence, cost, and payment. Critical Care Medicine, 32(11), 2247Y2253. Dopson, S. (2007). A view from organizational studies. Nursing Research, 56(4 Suppl.), S72YS77. Funk, S. G., Tornquist, E. M., & Champagne, M. T. (1995). Barriers and facilitators of research utilization. An integrative review. Nursing Clinics of North America, 30(3), 395Y407. Grathwohl, K. W., & Venticinque, S. G. (2008). Organizational characteristics of the austere intensive care unit: The evolution of military trauma and critical care medicine; applications for civilian medical care systems. Critical Care Medicine, 36(7 Suppl.), S275YS283. Green, M. L., & Ruff, T. R. (2005). Why do residents fail to answer their clinical questions? A qualitative study of barriers to practicing evidence-based medicine. Academic Medicine, 80(2), 176Y182. Herr, K., Titler, M. G., Schilling, M. L., Marsh, J. L., Xie, X., Ardery, G., et al. (2004). Evidence-based assessment of acute pain in older adults: Current nursing practices and perceived barriers. Clinical Journal of Pain, 20(5), 331Y340. Hutchinson, A. M., & Johnston, L. (2006). Beyond the BARRIERS Scale: Commonly reported barriers to research use. Journal of Nursing Administration, 36(4), 189Y199. Kenny, D. J., & Hull, M. S. (2008). Critical care nurses’ experiences caring for the casualties of war evacuated from the front line: Lessons learned and needs identified. Critical Care Nursing Clinics of North America, 20(1), 41Y49. Leininger, B. E., Rasmussen, T. E., Smith, D. L., Jenkins, D. H., & Coppola, C. (2006). Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq. Journal of Trauma, 61(5), 1207Y1211. Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Nursing Research January/February 2010 Vol 59, No 1S Malchow, R. J., & Black, I. H. (2008). The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Critical Care Medicine, 36(7 Suppl.), S346YS357. National Naval Medical Center. (n.d.). At a glance. Retrieved October 24, 2008, from http://www.bethesda.med.navy.mil/Visitor Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York: The Free Press. Schmelz, J. O., Bridges, E. J., Duong, D. N., & Ley, C. (2003). Care of the critically ill patient in a military unique environment: A program of research. Critical Care Nursing Clinics of North America, 15(2), 171Y181. Collaborating Across Services S21 TriService Nursing Research Program. (2004). Definition of evidencebased practice. Unpublished report. Bethesda, MD: Resource Center of Excellence. U.S. Department of Veterans Affairs. (2006). VA/DoD clinical practice guidelines. Retrieved June 25, 2008, from http://www.oqp. med.va.gov/cpg/cpg.html Walter Reed Army Medical Center. (2008). Day in the life. Retrieved October 17, 2008, from http://www.wramc.amedd.Army.mil/ Visitors/visitcenter/history/Pages/dayinlife.aspx Weisgram, B., & Raymond, S. (2008). Using evidence-based nursing rounds to improve patient outcomes. Medsurg Nursing, 17(6), 429Y430. Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. ICU Nurses’ Oral-Care Practices and the Current Best Evidence Ganz, Freda DeKeyser, RN, PhD;Fink, Naomi Farkash, RN, MHA;Raanan, Ofra, RN, MA;Asher, Miriam, RN… Journal of Nursing Scholarship; Second Quarter 2009; 41, 2; ProQuest Central pg. 132 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. feature article A Unique Collaborative Nursing Evidence-Based Practice Initiative Using the Iowa Model A Clinical Nurse Specialist, a Health Science Librarian, and a Staff Nurse’s Success Story ZACHARY R. KROM, MSN, RN, CCRN; JANENE BATTEN, MLS, AHIP; CYNTHIA BAUTISTA, PhD, RN, CNRN urpose/Objectives: The purpose of this article was to share how the collaboration of a clinical nurse specialist (CNS), a health science librarian, and a staff nurse can heighten staff nurses’ awareness of the evidence-based practice (EBP) process. Background/Rationale: The staff nurse is expected to incorporate EBP into daily patient care. This expectation is fueled by the guidelines established by professional, accrediting, and regulatory bodies. Barriers to incorporating EBP into practice have been well documented in the literature. Description of the Project/Innovation: A CNS, a health science librarian, and a staff nurse collaborated to develop an EBP educational program for staff nurses. The staff nurse provides the real-time practice issues, the CNS gives extensive knowledge of translating research into practice, and the health science librarian is an expert at retrieving the information from the literature. Interpretation/ Conclusion: The resulting collaboration at this academic medical center has increased staff nurse exposure to and knowledge about EBP principles and techniques. The collaborative relationship among the CNS, health science librarian, and staff nurse effectively addresses a variety of barriers to EBP. Implications: This successful collaborative approach can be utilized by other medical centers seeking to educate staff nurses about the EBP process. P KEY WORDS: clinical nurse specialist, collaboration, EBP, evidence based practice, health science librarian, Iowa Model, staff nurse, teaching Author Affiliations: Yale–New Haven Hospital, Connecticut (Mr Krom and Dr Bautista); and Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut (Ms Batten). Corresponding author: Cynthia Bautista, PhD, RN, CNRN, SP6-2, Yale–New Haven Hospital, 20 York St, New Haven, CT 06504 (cindy.bautista@ynhh.org). Clinical Nurse SpecialistA Copyright B 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 54 CLINICAL NURSE SPECIALISTA Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. T he expectation has grown that staff nurses will incorporate evidence-based practice (EBP) into their daily routine. Evidence-based practice is the standard for nursing care practice recommended by various regulatory bodies.1–4 Although these ideas are theoretically sound, staff nurses continue to experience difficulty incorporating EBP into their daily practice. Barriers that prevent staff nurses from implementing EBP have been well described in the literature.5–10 Nurses can overcome these barriers by collaborating with specialists outside the profession such as librarians as well as with informed colleagues such as the unit’s clinical nurse specialist (CNS). Diffusing the CNS expertise in nursing care to other nursing care providers allows the CNS to use credible evidence to guide nursing care, a competency that both the American Nurses Association and National Association of Clinical Nurse Specialists state that the CNS should possess.11 This project involved collaboration of the CNS with a staff nurse, and a health science librarian that resulted in an effective approach in addressing the barriers to EBP for staff nurses. The purpose of this article was to share how the collaboration can heighten staff nurses’ awareness of the EBP process. THE CNS ROLE The CNS is perfectly positioned to promote the EBP process to the bedside nurse. They can act as expert advisors for knowledge transformation because of advanced education, clinical specialization and expertise, and exposure to graduatelevel research. The CNS’s involvement with bedside practice, staff nurse mentoring, and education allows the CNS to directly impact patient outcomes. The CNS can help the bedside nurse ask questions, search for answers, critically appraise, and use the best evidence to optimize patient care. The CNS is in an ideal position to educate nurses and implement the many competencies needed for the bedside nurse to perform the process of EBP, because these competences fall well within the scope of the CNS’s job. Clinical nurse specialists can play an essential role in the development, application, and ongoing evaluation of an EBP program. A search of the literature reveals no one has published how the CNS can act as a facilitator for an EBP program, particularly his/her role to design, implement, and evaluate an EBP program. Managers and nurse educators have been seen as the ones who initiate the staff nurse into the EBP process.12 A CNS’s skills in program development and implementation are particularly valuable when an organization requires a change in the culture of nursing practice to get accredited. In this project, the application for Magnet status was the impetus for EBP education of staff nurses. The educational goal was to change the focus of the present nursing practice from traditional to evidence based. The organization’s nursing education group was called upon to make the change. A group of CNSs, some with doctorates, met to decide on the process to promote the use of EBP. The group agreed that staff nurses needed an easy model to follow in acquiring the skills to put evidence into practice. After reviewing several nursing ‘‘practice change’’ EBP models, the Iowa Model of Evidence-Based Practice to Promote Quality Care13was decided upon. The Iowa Model describes the step-by-step process of how to make a practice change by integrating evidence into VOLUME 24 | practice. It identifies areas of clinical inquiry and guides nurses to use research findings for improvement in patient care. After purchasing the Iowa EBP training kit and attending EBP nursing conferences, the nursing education group established the content of the program. At this point, the librarians were brought in to participate in the program. Together, the CNSs and the librarians created an EBP program. THE LIBRARIAN ROLE The librarians involved in this project recognized the challenges and barriers faced by nurses, so when they were asked by the CNS to become partners in teaching EBP, they readily agreed to participate. The recent study by Pravikoff and colleagues7 about information-seeking needs of nurses found that 61% of nurses reported needing information at least once a week. The report also pointed out that journal articles, research reports, and hospital libraries were seldom used; instead, nurses sought colleagues to answer their information questions.7 Nurses often perceive libraries to be ‘‘remote’’ from their workplace even if the library is within the same building or very close by.14 As specialists in accessing healthcare information, health science librarians are well placed to work closely with nurses for all of their information needs.15 They are surprised to learn that nurses do not know that the library and its resources are available to them. However, once nurses know about the library’s resources, they are usually very willing to learn how to use them.14 Librarians offer training in many different aspects of information seeking including database searching, what sources of information best answer nurses’ questions, and formulating questions to assist with the search process.14,16,17 Librarians are aware of the challenges that face nurses in accessing information and seek to become involved with clinical nursing staff wherever they can. Librarians have become partners in teams for Magnet status18–20 and working with nurses on the units.21,22 In this collaboration, there are two health science librarians who focus specifically on the needs of the nurses (with the library’s education coordinator working in an advisory capacity). One is the clinical librarian, who has direct responsibility as the hospital’s library liaison; the other is the nursing librarian, who works with the students and faculty at the school of nursing. Both librarians teach in the EBP classes for staff nurses, and both are available to work with staff nurses to help them to access the information they need. THE STAFF NURSE CHAMPION ROLE In most clinical settings, the ‘‘act’’ of doing EBP is not innate to the setting. Despite regulatory pressures, bedside nursing continues to be based on ‘‘the way we have always done it.’’8,23 The EBP process has to be taught to staff nurses and facilitated as a culture of improving practice in the clinical setting. The literature describes many potential EBP mentors including nurse educators and advanced practice registered nurses.24–26 Clinical nurse specialists and library personnel NUMBER 2 Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 55 were also mentioned as potential EBP mentors in a recent study.9 The nurse is fortunate to have internal resources (the CNS, the unit manager, and other staff nurses) and external resources such as librarians to assist them in finding the evidence. Using evidence as a basis for clinical practice requires staff nurses to understand how to ask clinical questions, find and appraise relevant literature, implement evidence, and evaluate outcomes. These skills are taught in baccalaureate nursing programs, but many staff nurses have been out of school for many years and may have forgotten these skills.27 Some nurses have never been exposed to research or had the opportunity to apply EBP in their clinical environment. Staff nurses can learn from others who model the use of EBP, such as other nurses and nurse managers. Electronic resources such as research databases are often used in the EBP process; however, the literature demonstrates that staff nurses lack confidence when it comes to navigating databases.7,28 This lack of confidence comes from not knowing what databases are available or how to use them effectively.8 If nurses do find literature to support practice, they need the skills to evaluate and critique research designs, analyze methods, and appraise the quality of research.5–7,29,30 Just as nurses need clinical skills to provide best practice, they also need to be able to assess whether the care being given is generating the highest possible patient outcomes. Such a culture change occurred when a small group of staff nurses in a critical care unit of a 944-bed university medical center formed a unit-based EBP committee. These nurses had received education on nursing research and statistics in their bachelor of science programs, but did not have the skills to apply the EBP process to the clinical setting to make a practice change. With the support of their manager, the nurses attended EBP classes taught by CNSs and health science librarians. The classes covered the process of EBP in detail, but at a level appropriate to the experience and education of the students. The unit-based EBP committee used clinical questions specifically asked by the staff in their unit to create presentations. The overall aim of the unit-based EBP committee was to inform and educate colleagues in best-practice recommendations based on information extracted from the literature. The committee addressed topics such as oral care in ventilated patients and family presence in resuscitative and invasive procedures. The presentations resulted in a number of clinical advancement and quality improvement projects. As the unitbased EBP committee’s work progressed, the group presented its model at regional, national, and international nursing conferences. The members became EBP champions in their unit and gained recognition in the institution. In addition to making presentations, the EBP champions assisted their colleagues in finding evidence to address clinical questions. They helped perform literature searches and referred staff nurses to the CNS and health science librarians when further information was needed. The staff nurse champion, realizing the value of learning and teaching EBP, approached the CNS (who was teaching the EBP classes) for her guidance and mentorship. As a result, the staff nurse began to teach EBP classes for staff nurses and new graduates at the hospital. The staff nurse champion continues to work closely with the CNS mentor 56 and the health science librarians, to identify and incorporate pertinent clinical issues into class content. THE COLLABORATION The collaboration among the CNS, the health science librarians, and the staff nurse champion shaped the course of the EBP activities and curriculum for staff nurses (Figure 1). Each brought an important perspective that would help the staff nurse become familiar with the concept and overcome any personal barriers. The program consisted of 3 parts that were covered over a day and a half and taught by the CNS and the librarians. In part 1, the CNS introduced the importance of EBP and reviewed the Iowa Model. The CNS also taught the staff nurses how to take a clinical question and create a PICO (patient/population, intervention/exposure, comparative intervention, outcome) question. Over time, the CNS mentored the staff nurse champion to teach these classes. In part 2, individual questions were developed, and nurses met with the librarians to search the literature for evidence. In part 3, the CNS taught them to critique and synthesize the evidence they found and to make a decision about a practice change. After several years of educating staff nurses about the EBP process, the CNS, health science librarians, and staff nurse champion decided to review the outcomes of the program and make revisions. Staff nurses who had attended the classes had commented that they still were unable to successfully search the literature to find evidence to their clinical question. The program was revised to teach the staff nurse the actual competencies of creating a PICO question and conducting a literature search; these skills were practiced several times. The revised program allowed each step of the Iowa Model to be reviewed (Table 1). In part 1 of the revised program, the CNS introduces EBP and the Iowa Model. The clinical librarian introduces the resources that the library has made available to all staff nurses and especially how they can access library resources from clinical workstations and from home. The nursing librarian then formulates questions and introduces the search process. The class introduces nurses to predefined nursing clinical scenarios, creating PICO questions for those scenarios. Nurses then learn to use databases to find answers to those questions. The class uses clinical scenarios that produce results, making the experience a positive one for the nurse. In using these predetermined scenarios, the nurses are made aware that potentially the questions that arise from their own practice may not be as ‘‘simple’’ as the examples used in class. However, it is impressed upon them that the librarians, the CNS, and the staff nurse champion are always available to assist. The staff nurses leave part 1 with an article and a critique model to study in preparation for the part 2 class. In part 2, the CNS develops the staff nurses’ skills in critiquing research articles, determining if there is sufficient evidence to make a practice change, and reviews the institution’s model for making a practice change. If sufficient evidence is not found, the questions are referred to the institution’s nurse researcher to conduct a study with the view to making a practice change. The evaluation of the practice change is discussed as well as how to disseminate the information. The revised program was designed to improve the nurse’s ability to transfer the EBP skills learned to their clinical practice. CLINICAL NURSE SPECIALISTA Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Figure 1. Roles in collaborative evidence-based practice initiative. The unique skills of each role are shown. The skills combined through collaboration result in successful EBP Nursing Program. The success of the 2-part formal classes increased awareness of EBP in the institution. These classes helped demystify the concepts of EBP and were an important step in the development of staff nurses. Class evaluations showed that nurses felt more comfortable with the search process. They also reported that the search process appeared to be a task that could be realistically accomplished during their clinical day. In tandem with the formal classes, EBP workshops are held on a monthly basis for all staff nurses throughout the institution as another way to expose them to the skills of EBP. All staff nurses are welcome to attend a workshop, and there is no need for prior EBP experience. Workshop content follows the steps described in the Iowa Model, and nurses learn about a particular skill related to EBP. Topics included in these workshops are research versus performance management, statistics, creating the clinical question, qualitative and quantitative research, writing an institutional review board proposal, searching evidence, critiquing articles, and presenting evidence. The workshops are brief and less formal to allow nurses not to be away from the bedside all VOLUME 24 | day, yet continue to aid in the discovery of how EBP can be related to bedside work. Some workshop participants enjoy the content and sign up for formal EBP classes. Workshop leaders include nursing professors, librarians, in-house content experts, and staff nurses. Evidence-based practice workshops are another way for staff nurses to gain knowledge and use the skills needed to include EBP in patient care. Another improvement to the EBP program was the formation of an EBP champion group. The CNS and staff nurse champion facilitate this group, which meets every other month. Members of this group had varying levels of experience with EBP or nursing research, so the initial group meetings were devoted to learning the steps of the Iowa Model. This was important because the goal of this group was for members to become informal mentors to their colleagues for the EBP process. The role of the staff nurse champion is to facilitate clinical question formation, initiate the preliminary search process for studies, call on the librarian if advanced searching is necessary, and request assistance of the CNS to interpret results of literature review. To NUMBER 2 Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 57 Table 1. Evolution of a Nursing Evidence-Based Practice (EBP) Program nurses cannot be expected to do this on their own. They need to collaborate with individuals who possess the tools to overcome these barriers. References Original Program Revised Program Formal classes Formal classes Part 1 Part 1 & Introduction to EBP & EBP overview/Iowa Model & IOWA Model overview & Welcome to library & Asking the right question & Creating clinical question & Managing the literature & Searching for the evidence & Strategies for making change happen Part 2 Part 2 & Tour of library & Critiquing and synthesizing & Refining the clinical question the evidence found & Conducting a literature search & Changing practice based on evidence & Disseminating results Part 3 & EBP literature resources & Critiquing and synthesizing the evidence Informal classes & EBP workshops practice the skills they were learning, the group decided to look at peripheral intravenous device–securing techniques, and this clinical question is still under way. The EBP champion meetings have allowed the members to develop their skills in the EBP process. In an effort to increase staff exposure to EBP outside the structured programs, the CNS has become a well-known consultant for practice issues. Informal mentoring sessions are scheduled in patient care areas. During these sessions, the CNS facilitates the search for information and educates the staff on the principles of EBP and the Iowa Model. If additional information or assistance is required by the groups, the CNS suggests contacting the librarian. This suggestion often opens dialogue about the electronic resources available to staff. Many of the questions addressed so far by the CNS have become quality improvement projects or resulted in practice changes. A small number of these projects are presently under consideration by the nursing research committee at the hospital for research support. CONCLUSION The collaboration of the CNS, the health science librarian, and the staff nurse champion is to increase nurses’ knowledge of EBP. Each is acutely aware of the barriers for staff nurses to conduct EBP. Together, they use individual strengths and experiences to educate and apply the many competencies needed for the staff nurse to perform the process of EBP (Figure 1). Nursing EBP is the level of care that staff nurses are expected to provide. Considering the multitude of barriers, 58 1. American Nurses Association. Nursing : Scope and Standards of Practice. Silver Spring, MD: Nursesbooks.org: American Nurses Association; 2004:160. http://www.loc.gov/catdir/toc/ecip049/ 2003020741.html. Accessed March 16, 2009. 2. American Nurses Credentialing Center. System eligibility requirements. American Nurses Credentialing Center Web site. Updated 2008. http://www.nursecredentialing.org/Magnet/ApplicationProcess/ EligibilityRequirements/SysEligibilityRequirements.aspx. Accessed April 15, 2009. 3. National Quality Forum. Information technology and healthcare quality: a national summit. National Quality Forum Web site. 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Clinical Nurse Specialist’s author guidelines are available at www.cns-journal.com. VOLUME 24 | NUMBER 2 Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 59

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