Marita G. Titler, PhD, RN, FAAN

Senior Assistant Director, University of Iowa Hospitals and Clinics

Director, Research, Quality and Outcomes Management

Department of Nursing Services and Patient Care, UIHC

Director, Institute of Translational Practice, 

Center for Research in the Implementation of Innovative Strategies in Practice, Department of Veterans Affairs 

Laura Cullen, MA, RN, APN

Evidence-Based Practice Coordinator

Research, Quality and Outcomes Management

Department of Nursing Services and Patient Care, UIHC

Educational Strategies for Clinicians

Strategies to Implement EBP

Evidence-Based Decision Making

Organizational

Infrastructure

Quality Patient Care

Objectives
        - To overview two educational programs for staff that address promoting use of EBPs

Staff nurse internship for EBP

Advanced Practice Institute for EBP

Others we have

Nurse Managers

Senior Leaders

The Evidence
        - Nurses at the point of care delivery are in the ideal position to ask & answer clinical questions 
        - Need strategies that link clinicians with evidence
        - Several steps in the EBP process are challenging
        - Application oriented approach with active facilitation is necessary to learn the process

Cullen & Titler, 2004; Ellis, Howard, Larson & Robertson, 2005; Estabrooks, Chong, Brigidear & Profetto-McGrath, 2005; Estrabrooks,  Rutakumwa, O’Leary, Profetto-McGrath, Milner, Levers & Scott-Findlay, 2005; Fink, Thompson & Bonnes, 2005; Johnson & Mighten, 2005; Pravikoff, Tanner & Pierce, 2005; Robertson, Umble &  Cervero, 2003; Schultz, Whiting, Kent, Keane & Gallant, 2004; Thomson O’Brien, Freemantle, Oxman, Wolf, Davis & Herrin, 2001; Waddell & Dunn, 2005   

The Evidence (con’t)
        - Complex skills are needed for leading EBP initiatives
        - Leadership is essential for success
        - Evidence-based practice work must be resourced to succeed
        - Translation research is a young/growing science; use of effective strategies for implementation is not broadly understood

Berwick, 2003; Greenhalgh, Robert, Bate, Macfarlane & Kyriakidou, 2005; Kirchhoff, 2004; Ravaud, Keïta, Porcher, Durand-Stocco, Desmonts & Mantz, 2004; Rogers, 2003; Schultz, Whiting, Kent, Keane & Gallant, 2004; Simon, Majumdar, Prosser, Salem-Schatz, Warner, Kleinman, Miroshnik & Soumerai, 2005; Thomson O’Brien, Oxman, Davis, Haynes, Freemantle & Harvey, 1997; Titler, Cullen & Ardery 2002; Titler & Everett, 2001; Tranmer et al, 1998; Van Mullem et al, 1999

Audience
        - Staff nurses

Evidence-Based Practice Staff Nurse Internship
        - Nursing leaders

Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice

Evidence-Based Practice 

Staff Nurse Internship

Strategies to Implement EBP

Evidence-Based Decision Making

Organizational

Infrastructure

Quality Patient Care

Purpose
        - Stimulate innovative thinking about efficient and effective practices to improve patient outcomes
        - Use the Iowa Model of Evidence-Based Practice to Promote Quality Care
        - Assist staff nurses with application of the evidence-based practice process 
        - Foster professional growth and development of staff nurse interns at UIHC

Course Overview
        - Pilot program 2001
        - Funding
        - Mass mailing of brochures
        - Basic eligibility criteria
        - Simple application
        - Signed contract
        - Competitive review process
        - 18 month program
        - 12 meetings/year
        - Facilitated work time
        - Staff nurse, APN, & NM teams
        - Administrative support
        - Free CEUs

The training program

Acceptance criteria:

Minimum of 2 years nursing experience

At least 1 year on current clinical area

Employed  50%

Interest in learning about EBP

Partnership among STN, NM & APN

Leadership skills

Distinguished clinical performance

Schedule

Day 1:	Understanding the Iowa Model

Day 2: 	Application of the Iowa Model and The Translation Research Model

Day 3:	Synthesis of the Evidence

Day 4:	National Evidence-Based Practice Conference

Days 5-12:	  Implementation & Evaluation

Based on observation and feedback, we need to make changes in the schedule.

A full evaluation is pending, so we will take those recommendation into consideration before developing the next internship.

Expectations of Interns
        - Process

Full participation in and completion of the coursework

Regular meetings with the leadership team

Work with appropriate committee in developing the practice protocol (e.g., Professional Nursing Practice committee)
        - Project Outcomes

Development, implementation and evaluation of one project

Dissemination of project results
        - Peer Influence

Promote use of evidence to guide practice

Promote change in the clinical area

List of Projects
        - Pet visitation
        - Suicide risk assessment
        - Sedation management
        - Guided imagery
        - Bowel sound assessment
        - NG placement for children
        - Enteral feeding
        - Occipital pressure ulcers
        - OR handscrub
        - Fall risk assessment
        - Double gloving
        - Family transfer from PICU
        - Dietary restrictions
        - Patient education for otological procedures
        - Communicating end-of life wishes

New Cohort 2007
        - Pediatric Palliative Care 
        - Bedside Swallow Screen
        - Blood Pressure Monitoring 
        - Psychiatric Advanced Directives (PADs) 
        - Sleep Deprivation
        - Thermoregulation of High Risk Neonate
        - Perineal Dermatitis

http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/internship.html

Evaluation – initial cohort
        - Evaluation of the course content by attendee
        - Critique of the program by NM, APN and staff nurse with recommendations for improvement
        - Completed implementation and evaluation of an evidence-based practice project, including dissemination
        - Performance evaluation to include participation and outcomes of the program

Evaluation is of pilot program is complete

Evaluation Results: Qualitative
        - “I know the knowledge-based for the cutting edge information of EBP”
        - “The opportunity for professional growth has been provided”
        - “Recognition that the STN observes situations/topics which need to be changed and receiving support to do this”
        - “I think integrating this into nursing will be a huge plus, not only for UIHC but nursing.”
        - “It has given me a huge self-esteem boost and I hope this internship continues for more and more nurses.”

--Intern feedback, June 2001

          - Qualitative feedback to open-ended questions was striking and positive:
          - “I know the knowledge-based for the cutting edge information of EBP”
          - The opportunity for professional growth has been provided
          - Recognition that the STN observes situations/topics which need to be changed and receiving support to do this.
          - I think integrating this into nursing will be a hugh plus, not only for UIHC but nursing.
          - It has given me a huge self-esteem boost and I hope this internship continues for more and more nurses.

Focus Group Feedback – Initial cohort

Staff Nurses
        - Motivated by change
        - Partnership was critical
        - Time
        - Opportunity for growth
        - Coordination
        - Class content revisions
        - Mentorship

Nurse Managers
        - Time
        - Coordination
        - Mentorship
        - Dissemination of results
        - Application process

APNs
        - Time
        - Partnership for resourcing
        - Coordination
        - Growth opportunity
        - Program revisions

Final Evaluation

*n = 16; 2002-06 combined data

Strongly Disagree

Strongly Agree

Program evaluation done on last work day

Scale 1-5 (1=strongly disagree; 2=disagree; 3=uncertain; 4=agree; 5=strongly agree)
          - I understand the process for using evidence-based practice at UIHC
          - The Evidence-based pracatice internship program helped me grow professionally
          - I understand how to use the Iowa Model of Evidence-based Practice to Promote Quality of Care
          - The Evidence-based practice internship program stimulated my innovative thinking

Interns’ Additional Comments
        - “This program is a wonderful opportunity for STNs to make a difference”		-- Intern feedback, February 2002
        - “I have had the idea for the project for a long time. I didn’t know how to proceed or how to get the support I needed.  The internship provided both for me”. 				-- Intern feedback, May 2003
        - “I feel that I will get more out of this then I could ever put into it”!! 		-- Intern feedback, May 2003
        - “I think the more skilled the mentor in EBP, the more productive the project becomes.” 

						-- Intern feedback, February 2006

Keys to Success
        - Topic selection by STN’s
        - Competitive review of applications
        - Paid release time from clinical responsibility
        - Summer and holiday schedule
        - Regularly scheduled work sessions
        - Matching clinical, systems and EBP expertise
        - Beginning work sessions with a project update, troubleshooting & team building

Broad distribution of applications:  allowed STN’s to choose to participate (not just the “teachers pet”)

Topic selection by STN’s

Use of application, letter(s) of support from NM (would add APN) & contract

Creating teams: STN, NM, APN, & adding members as appropriate (e.g., EBP facilitator and clinical experts) from UIHC or College of Nursing

Project Integration
        - Sustaining the projects is a priority (STN feedback; NM focus group feedback, February 2002)
        - Process involves:

Reporting results to the Nursing Research Committee

Development of QI goal and monitoring

Development of education (orientation, competency review, temporary staff, etc.)

Revisions in documentation to support practices

Reporting results to Nursing QM Committee

Staff Nurse Recognition

Celebrate Success

Awards
        - Sigma Theta Tau                                 International EBP Award
        - UIHC People’s Choice Award
        - AORN Poster Award
        - Colleen Goode EBP Poster Award
        - UIHC Recognition Day                            Poster Award

Summary
        - Empowering for STN’s

Staff felt valued & gained confidence

Recognition for a job-well-done
        - Networking across department and multidisciplinary
        - Evaluations led to program revisions 
        - Support from APN/NM mentors & research office is critical
        - Positive impact on outcomes

Overall evaluation results were quit positive.

We have developed the API to address one suggestion from the APN focus group feedback.

Additional revisions in class scheduling will be needed in future programs.

Revisions in coordination of projects within unit structures will be needed in future programs.

We would like to support the intern-APN team work to increase their time together.

We look forward to continuing the EBP Internship Program.

Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice

Strategies to Implement EBP

Evidence-Based Decision Making

Organizational

Infrastructure

Quality Patient Care

Goals and Purpose
        - To promote advanced skills of nursing leaders in use of evidence-based practice models.
        - To develop leadership skills for facilitating completion of clinically relevant evidence-based practice projects.
        - To foster networks for creative thinking and issue resolution in the evidence-based practice process.
        - The purpose of the Institute is to educate nursing leaders to guide colleagues and staff in the integration of evidence-based knowledge into practice. 

Objectives
        - Identify strategies for implementing                       and sustaining evidence-based practice              changes in complex health care systems.
        - Describe the organizational infrastructure necessary for evidence-based practice.
        - Utilize the toolkit provided to promote evidence-based practice.
        - Train other nurses in the evidence-based practice process.
        - Develop a specific evidence-based practice clinical topic.

Overview
        - Three day intense workshop
        - Prerequisite preparation and homework
        - Limited group size
        - Small group and individual consultations
        - Application oriented
        - Emphasis on most challenging steps

Prerequisites
        - Overview of Iowa Model

Readings

Web-based CE course
        - Addressing challenges in EBP

Readings
        - Critique research articles

Schedule
        - Day 1: 

Topics and teams

Locating, critiquing and synthesizing the evidence

Building an implementation plan
        - Day 2: Implementation and Evaluation
        - Day 3: 

Sustaining change

Roles and project exemplars

Building the infrastructure and program

Expectations and Resources
        - Apply information shared and project developed during Institute
        - Complete an EBP project
        - Develop leadership skills for facilitating EBP within their organization
        - Receive Toolkit and extensive resources for their project and EBP process
        - Consultation on-site and after the program

Evaluation

Evaluation

Additional Comments
        - “This was the best workshop I’ve ever attended.”
        - “I was in awe of the level of expertise and education of the faculty.  It was very impressive to see what you have accomplished.”			-2003
        - “Immersion into the ‘world’ of EBP, the tremendous overview and detail gave me what I need to support my organization as it evolves in this excellent method of care delivery.” 			-2003
        - “This was an awesome experience-really feel I can proceed with my project now and succeed.” -2005

Additional Comments
        - “The energy in the room was great both with the participants and instructors-as well as the staff nurses who presented. It was great to have people enthusiastic about improving patient care. I found this so refreshing because nurses historically put down other nurses and frequently stagnate other nurses. This was the complete opposite-nurse helping nurses-what a novel idea. All nurses should take this course-period! Administrative and clinical.”	-2004
        - “This was the best group I have been involved with in a long time.  The expertise and sharing was fabulous.”							-2006

Keys to Success
        - Small group of participants
        - Application oriented
        - Emphasis on implementation and other most challenging steps
        - Networking opportunity
        - Extensive number of useful resources
        - Project focused consultation and work time
        - Large group of expert faculty and consultants

Long-Term Program Evaluation
        - Questionnaire:

Sent January 2007

Program attendees from 10/02-3/06 at UIHC

Response rate = 33/94 (35.1%)
        - Respondents:

2/3 attended 1-1 1⁄2 years prior 

Mean 2 years since attending the Institute

Program Impact
        - Institute was helpful in addressing challenges (mean 4.1 on 1-5 scale; 85% agree or strongly agree)
        - Project completion:

30% completed their project

42% still working on their project

36% working on a different project
        - Outcomes:

Patient impact (79%)

Staff impact (67%)

Fiscal impact (39%)

Other: “I truly believe we would not have received Magnet status without the tools from Iowa to establish EBP here.”

Program Impact
        - Shared knowledge gained from the Institute (100%)
        - Made changes within organizational infrastructure (82%)
        - Developed strategies for expanding EBP within their organization (91%)
        - Have formal responsibility for EBP within a specific role or committee (65%)

Application of Program Content

Mastery of Advanced Skills
        - Data collection for project evaluation (3.72)
        - Planning the pilot (3.69)
        - Managing a team (3.69)
        - Developing an action plan (3.66)
        - Modifying practice recommendations based on pilot (3.66)
        - Developing an evidence-based practice policy (3.64)
        - Prioritizing topics (3.58)

Rated on 1-4 scale; not able to completely able

Advanced EBP skills that were rated highest for mastery

Implications
        - Facilitation is essential
        - Educators: Develop academic and continuing education to promote skill development

Evidence: locating, critique, analysis & synthesis

Data interpretations: statistical process control charts

Evidence promoting sustainability of EBP changes
        - Leadership: Develop capacity, support, expectations and commitment to the journey

1-4 scale; not able to completely able

Advanced EBP skills that were rated lowest, need to be emphasized in educational programs; are also amenable to skill development in academic programs:

Interpreting data using statistical process control charts (2.9)

Integrating and sustaining practice changes (3.22)

Critiquing research (3.24)

Determining strength of the evidence (3.27)

Using electronic resources to locate best evidence (3.33)

Summary
        - EBP work can be challenging
        - Unique educational strategies are needed
        - Distinct programs address audience learning objectives (e.g., basic and advanced)
        - Programs can be successful using a learn by doing approach with sufficient facilitation 
        - Evaluations are positive and healthcare outcomes improve

Is Practice Based on Evidence?

TRADITION

Internship: 

Cullen, L. & Titler, M.G. (2004).  Promoting evidence-based practice: An internship for staff nurses.  Worldviews on Evidence-Based Nursing,1(4), 215-223.

Institute: http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/apinstitute.html

State of nursing science is incomplete; Effective searching for evidence becomes all the more important as we gain an increasing emphasis on use of evidence in practice

Search for evidence can be a challenge; requires skills in seeking knowledge; Use of standardized language has an expanding need and is required for effective searches

Difficult decisions for practice must be based on multiple forms of evidence

Nurses need assistance formulating a question and synthesizing the evidence (Camiletti & Huffman, 1998)

Synthesis of evidence requires an APN

Questioning practice is essential to progress

Clinical experts are critical to success

Conclusions:
          - Nursing maintains the tradition of auscultation of bowel sounds
          - Nursing evidence for practice is completely lacking
          - UIHC surgeons list other parameters as more important
          - Finding and synthesizing evidence can be a challenge
          - Basic science research does not support use of bowel sounds as an indication of return of motility s/p abdominal surgery
          - New nursing procedure for assessing return of GI motility after abdominal surgery needs to be evaluated

Additional Reflections 
        - Demand is high 
        - Nurse driven interdisciplinary improvement of care delivery
        - Return on investment is good
        - Mentorship at the organizational level

ANMC

St. Cloud, Minn.
        - Interdisciplinary program 
        - Intensive yet fun