1. Building Capacity for Evidence-Based Practice in a Clinical Setting QSEN Conference San Antonio, Texas May 26, 2016
Carol Klingbeil, DNP, RN, CPNP-PC
Clinical Assistant Professor of Nursing UW-Milwaukee
APRN- Urgent Care Children’s Hospital of WI

2. Disclosure Statement
There are no relevant financial relationships related to this presentation.
There is no sponsorship/commercial support of this presentation.
The content being presented will be fair, well-balanced and evidence-based.

3. Learning Objectives
Share results from a mixed-methods study conducted to provide recommendations for the enhancement of an EBP Program at a Midwest Children’s Hospital.
Explore recommendations for future advancement of EBP in the organization.
Evidence-based practice (EBP),  is the use of the best current evidence in making decisions about the care of the individual patient.   EBP also integrates clinical expertise and takes patient desires, values, and needs into consideration.
Qualitative study with focus groups of nurses from different roles: 2 levels of leaders (executive and unit level), APNs/system level nurse roles in quality/care management and staff nurses (33 in all)
Themes and subthemes analyzed by study team.
Confirmed 4 themes of barriers, infrastructure, mentorship and leadership; 3 new ones emerged culture, vision and priorities.

4. EBP
“Integration of best research evidence with clinical expertise and patient values.”
-Sackett et al, 2000
Evidence-based practice (EBP),  is the use of the best current evidence in making decisions about the care of the individual patient.   EBP also integrates clinical expertise and takes patient desires, values, and needs into consideration.

5. What’s the problem?
Despite aggressive research agenda, the majority of findings are not integrated into practice.
It takes way too long to translate research findings into practice.
17 years
Less than half of nurses using EB guidelines while treating patients. (2012, ANA and Ohio State university)

6. Drivers for EBP The Institute of Medicine (IOM)
ANCC Magnet Recognition Program
Quality and safety issues
Consumer groups
Policy implications related to health equity care and cost issues
IOM Recommendation that 90% of decisions made in healthcare be evidence based by 2020 (Olsen, Aisner, & McGinnis, 2007).
Nursing excellence through clinical inquiry as a hallmark of quality care and improved patient outcomes (American Nurses Credentialing Center, 2008)
If their full potential is to be realized, however, the nursing profession itself will have to undergo a fundamental transformation in the areas of practice ,education, and leadership. During the course of this study, the committee formulated four key messages it believes must guide that transformation:
nurses should practice to the full extent of their education and training;
nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression;
nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States; and
effective workforce planning and policy making require better data collection and an improved information infrastructure.
ANCC Magnet focused on nursing excellence as a hallmark of quality care and improved patient outcomes (American Nurses Credentialing Center, 2008).

7. Background
Evidence related to impact of EBP activities and culture on:
Quality & Safety
Better care based on evidence =30% better outcomes
Safe and effective care
Higher nurse satisfaction leading to improved staff retention (Magnet)
Patient Satisfaction improved
Further, evidence-based practice improves patient outcomes as compared to traditional practice. Research has shown patients who receive care based on evidence from well-designed studies experience nearly 30 percent better outcomes.2
Magnet hospitals provide evidence that Environmental factors that contribute to a positive work environment and increased nurse satisfaction included: safe, effective patient care
30 to 40% of hospitals are not meeting benchmarks for NDNQI performance metrics
20 to 30% of hospitals are above national benchmarks for core measures (e.g., falls, pressure ulcers)
Disconnect between understanding EBP, quality and safety measures.

8. Current State at CHW and EBP Model
EBP Policy
EBP and Research Council
Active Research Department with 4 nurse scientists
EBP Education Series
Yearly EBP Fellowship
Iowa Model
Who comes from an organization that uses a specific model. How have you used them?
2015 update with emphasis on interdisciplinary team, implementation & sustainability
newly updated April 2015 with emphasis on interdisciplinary team, implementation & sustainability
simple to use algorithm
feedback loop

9. Iowa Model Identify the trigger Determine organizational priority
Form a team
Gather evidence
Critique and synthesize evidence
Determine if evidence is sufficient
Pilot change
Determine if change appropriate for practice
Implement and monitor
Disseminate results

10. Purpose of study Program evaluation with 3 components: Focus groups
Quantitative: Surveys
Qualitative: Focus groups
Benchmarking of other hospitals
Focus groups
33 nurses, 1 hour interviews with question guide
6 executive leaders, 6 unit focused leaders, 7 staff nurses, 8 APN/CNS & quality/advanced roles
DNP project
Why we wanted to do this!
Council, Magnet
Current state of EBP at CHW.
Questions were focused on barriers, things that would support EBP known in literature around infrastructure, mentoring, leadership.
Confirmed 4 themes and 3 emerged: culture, vision and priorities.

11. Question/Method
What are the themes related to EBP barriers and advancement of EBP when interviewing groups of stakeholders such as staff nurses, leaders and APNs?
Focus groups
33 nurses, 1 hour interviews with question guide
6 executive leaders, 6 unit focused leaders, 7 staff nurses, 8 APN/CNS & quality/advanced roles

12. Evidence Provided framework for the question guide: Barriers
Infrastructure
Mentorship
Leadership
Looking at the evidence supported my questions for the focus groups. Data analysis focused on analysis of themes and then sub-themes confirmed by the study team.
What are the barriers we face as an organization related to advancement of an EBP culture and increasing EBP activities in the organization?
What is your vision for the organization or for your individual department or unit, in regards to success and growth of the staff nurse and inter-professional teamwork focused on EBP?
What do you see as your role in leading and supporting this advancement for EBP at CHW?
What areas do you feel that staff would need the most support and mentoring with to carry out EBP?
What institutional infrastructure is needed to promote more EBP projects and access to evidence at the bedside?

13. Known Barriers Literature Study time
difficulty critically appraising the evidence
lack of administrative support
lack of mentoring
lack of authority to change patient care practice
continue to use peers and colleagues more than evidence for clinical questions
time consuming
overwhelming & cumbersome
unsure how to start
not sure who the mentors are
budget/staffing for nurse replacement while doing EBP
demands of patient care
complexity of changing practice & push back with too much change
medical model/provider push back
competing priorities
Bartelt et al., 2011; Linton & Prasun, 2013; Straka, Brandt, & Brytus, 2013; Pravikoff, 2006; Titler & Everett, 2006
Question
What are the themes related to EBP barriers and advancement at the organization when interviewing groups of staff nurses, leaders and APNs.
Qualitative study with focus groups of nurses from different roles: 2 levels of leaders (executive and unit level), APNs/system level nurse roles in quality/care management and staff nurses (33 in all)
Themes and subthemes analyzed by study team.
Confirmed 4 themes of barriers, infrastructure, mentorship and leadership; 3 new ones emerged culture, vision and priorities.

14. Quote
“All these hospital things and then you find these golden nuggets like the EBP, but where do you slide it in because it’s not on the hospital’s global plans. It doesn’t align. The clinical question -- where does that fall? I think it gets lost.”
From a nursing supervisor

15. Evidence Infrastructure Mentorship Leadership Culture
Limited evidence although connected with leadership evidence.
Mentorship has the biggest impact on EBP beliefs, readiness & confidence to implement.
Leaders must role model EBP.
Must advocate for infrastructure support.
Limited yet merging evidence;
Leadership connections.
Mentorship quality a factor; mentor skills as well as EBP knowledge & skills.
Must value & articulate it in strategic plan.
Need to support mentors.
Clinical inquiry valued
Provide funding for dissemination.
Flodgren et al., 2012; Melnyk (2010) and Melnyk (2007);Melnyk, Fineout-Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010; Wallin, 2009; Sredl, et al., (2011) Melnyk & Fineout-Overholt, 2012
Melnyk & Fineout-Overholt, 2012
Although CNOs believe EBP results in higher quality of care, safety and improved patient outcomes, very little of their budgets allocate funds for EBP and it is listed as low priority
Although CNOs reported top priorities are quality and safety, EBP is rated as a low priority
Summary: The greatest evidence for nursing and EBP is in the area of documentation of barriers for EBP, while the evidence related to interventions to promote EBP, successful models of EBP and EBP implementation are limited. There is a fairly strong evidence base for the value of mentorship in the advancement of EBP in organizations and emerging strength in the evidence that leadership and infrastructure play in strengthening EBP implementation in organizations.

16. Focus Group Results Mentorship Leadership Unclear who are the mentors.
Need more with mentor training.
Need small projects to build experience/confidence in mentoring.
Need to leverage more roles in organization who can mentor: APNs, CNS, MD, DNP, supervisors, previous EBP fellows.
Need to support CNS mentorship role & help them carve out time.
Practice changes need careful articulation with evidence as rationale for change.
Connect people and resources; limit silos.
Many competing priorities; EBP needs to be aligned with priorities.
Empower and set expectations.
Focus on staff accountability for EBP.
Support dissemination both internally and externally.
Celebrate and highlight successes.
Question
What are the themes related to EBP barriers and advancement at the organization when interviewing groups of staff nurses, leaders and APNs.
Qualitative study with focus groups of nurses from different roles: 2 levels of leaders (executive and unit level), APNs/system level nurse roles in quality/care management and staff nurses (33 in all)
Themes and subthemes analyzed by study team.
Confirmed 4 themes of barriers, infrastructure, mentorship and leadership; 3 new ones emerged culture, vision and priorities.
Quantitative baseline data collected as well.

17. Quote
“Leadership roles need to advocate, energize and articulate it in all forums”.
From a Unit Director

18. Culture, Vision & Priorities
Recent study results
Infrastructure
Culture, Vision & Priorities
Department of EBP needed to coordinate resources and mentors.
Need a visual to help simplify process and identify resources.
Lack of knowledge of existing resources: librarian, EBP and Nursing Research Council, mentors.
Needs to be more visible on evaluation.
Organizational process to answer clinical questions needed.
Leverage students in MSN or DNP programs; list of project options and track their progress.
Focus on sustainability of changes.
Funding for projects.
Need to capitalize on being a learning organization and being curious.
Culture of clinical inquiry needs to be promoted and prioritized.
Set the expectation for professional practice.
Link it with other culture focused initiatives such as safety and quality.
Need to emphasize the benefits, potential outcomes and cost savings.
Must make it easier, approachable, simpler, more for every man on the street, instead of thinking about it as big long projects.
Qualitative study with focus groups of nurses from different roles: 2 levels of leaders (executive and unit level), APNs/system level nurse roles in quality/care management and staff nurses (33 in all)
Themes and subthemes analyzed by study team.
Confirmed 4 themes of barriers, infrastructure, mentorship and leadership; 3 new ones emerged culture, vision and priorities.
Quantitative baseline data collected as well.

19. Quote
“Now is the time to emphasize curiosity and that we are a learning organization to get this to be a part of the culture. We’re slowly changing the culture to being curious and staying up on the mood elevator by saying, ‘Boy, that’s interesting, is that something that might work here?’”
From an APN

20. Quote
“Articulating vision with a big picture view for what could be, is important to come from leaders.”
From an executive leader
“You don’t hear people talking about it enough on the units. We need to build on the dedication that staff have and the passion that is here”.
From a staff nurse

21. Survey Nurse beliefs (EBPB) 16 items Implementation (EBPI) 18 items
Culture & Readiness for EBP (OCRSIEP)
26 items
Standardized tools
established internal consistency Cronbach’s alpha scores >.85 reliability (Melnyk et al., 2008).
Return rate
Perceptions of beliefs and values about EBP
Implementation asks about how often in past 8 weeks have you implemented a particular skill.
Culture and readiness asks about perceptions related to the organization
face, content and construct validity culture and readiness for system-wide implementation of EBP.

22. Characteristics of Nurses Participating in the Survey (n=466)
Survey: Sample
Characteristics of Nurses Participating in the Survey (n=466)
Primary Role
Highest degree
Experience (number of years)
Previous Experience
Staff nurse 285 (62)
APN (14)
Leaders (10) No report (14)
Diploma (5)
AD (10)
BSN (62)
MSN (20)
PhD (1)
DNP (2)
< (16)
5< (17)
10< (15)
15< (11)
> (41)
Research (24)
EBP Project 73 (16)
QI Project (43)
(yes or no; could answer more than one)
The majority were staff nurses, prepared at or above BSN, and experienced. “ although lowest experience is with EBP. Survey sent out to 1500 with 29% response rate over a 4 week period.
Don’t say this: No report missing data is asked due to branching.

23. EBP Scale Frequencies and Reliability Scores
Survey Descriptives
EBP Scale Frequencies and Reliability Scores
Scale
Beliefs
n=430
Implementation
n=396
Culture/readiness
n=103*
Mean SD
Item mean range
Cronbach’s alpha
3.65
0.45
0.95
1.85
0.87
0.86
3.30
0.60
0.91
*APN/leaders only
Strong Cronbach’s alpha consistent with previous studies showing strong internal consistency.
Mean of 3.65 on beliefs 1-5 approaching agree on strongly disagree to strongly agree scale.
1.84 on the implementation scale means that staff applied to them in the past 8 week period, examples are used evidence to change my clinical practice, etc means about 3-4 times in an 8 week period. So a fairly rigorous scale.
3.30 mean on the culture scale which was completed by only APNs and leaders means been ready but not acting vs ready to go for system-wide implementation of EBP.

24. Survey: Role Difference
EBP Scale Means and Differences by Role
Scale
Beliefs n=430
M (SD) F (2,373) =1.30,
p =.274
Implementation n=396
M (SD) F (2,340) =19.72
p =.000
Culture/readiness n=103*
M (SD) t (70.53) = 1.15
p =.256
Staff APNs
Leaders
3.61 (.43)
3.72 (.56)
3.61 (.44)
1.66 (.72)
2.31 (1.02)
2.22 (1.03)
3.26 (.59)
3.33 (.59)
*APN/leaders only
The implementation scale revealed a lower scale on implementation for staff nurses at first pass. However, the scale is quite rigorous asking about actual implementation in the past 8 weeks for activities such as “used evidence to change my practice, collected data on a patient problem and generated a PICO question.” A mean of 1.66 actually approaches the level of 3-4 times in an 8 week period which is impressive for the staff nurses role.
The scores for culture of readiness for EBP did not reveal differences in the roles of the APN/CNSs and leaders however it is important to note the absence of staff nurses on this measure due to the concern for measurement burden. Several questions in the culture scale are interesting.
When asked to rate the institution’s readiness for EBP on a scale of 1-5 (1= not ready, 2=getting ready, 3=been ready but not acting, 4=ready to go and 5=past ready and onto action) the 3.2 score for “been ready but not acting” may derive some meaning for the organization in regards to priorities.
An additional summary question asking “compared to 6 months ago, how much movement in your organization has there been toward an EBP culture?” presented a similar picture (2.78). This may suggest that enhancements in the program through infrastructure, leadership and mentorship may in turn support a more prominent vision and culture around the priorities of EBP for the organization.

25. Survey: EBP Education and Role Differences
EBP Scale Means Signif. Differences by Role and EBP Education
Scale
Belief All
Education n Mean(SD) Statistic
no (.44)
yes (.47) t (174.66) = p=.012
Implementation All
Staff Nurses
no (.80)
yes (.93) t (14.41) = p =.001
no (.64)
yes (.92) t (58.80)= p = .004
There were Sig different beliefs in the total sample  for those that had attended or not attended the EBP series with those attending having more positive beliefs. There were also sig differences in the total sample and the staff nurse sample with those attending EBP implementing  more EBP activities
Consistent with the literature supporting the role of a formalized EBP education intervention for nurses and especially for staff nurses as a means to provide foundational skills to build on with further mentorship of staff nurses.

26. Benchmarking 5 hospitals with 1 hour phone interview Themes:
Many differences and variations but all have a culture of EBP and display evidence on a yearly basis that EBP is alive and well.
Committee structure varies but work infused with strong EBP foundation.
Overlap with quality, research and EBP and moving to inter-professional work.
All have dedicated FTEs for leadership, education and mentoring EBP.
Regular education offered(series and monthly).
P & P process with leveling of evidence available for staff to view.
Regular showcasing, celebrating EBP efforts internally and externally.
Dedicated support for external dissemination across all 5 hospitals.
Nurse Residency Program is a major source of projects and education for all 5 hospitals. Setting the culture and expectations up front.
5 hospitals with 1 hour phone interview

27. Program Evaluation Conclusions
Nurses believe in the value of EBP and report emerging implementation practices.
All groups of nurses recognize the foundation of EBP but the need to enhance infrastructure, mentorship and leadership to address barriers for advancing EBP in the organization.
Moderately strong culture and readiness for EBP as reported by the organization’s administrative and clinical leadership teams.
Barriers similar to previous studies. Nurses went beyond the barriers to make recommendations.
Nurses from all roles in the focus groups recognized the importance of culture, vision and setting priorities in order to advance EBP in the organization.
Benchmarking adds additional support for recommendations.
Ready but not acting.

28. Organization Recommendations
Many specific recommendations to further advance EBP
Visual tool to simplify process & identify resources.
Identified lead and department for EBP needed for coordination.
Continue the EBP Series
Needs to be a shared vision about EBP that is articulated by leaders and staff.
Connecting EBP with other initiatives important.
Partner with students and faculty.
Build the mentor pool through dedicated mentor education and support.
P & P process needs refinement to include a more systematic evidence base, reporting of evidence with leveling and possible representative with EBP lens.
Connect with Transition to Practice program/Residency to find opportunities to add to curriculum.
Communicate and celebrate in meetings and forums.
Assisted by the EBP and Nursing Research Council to set priorities for recommendations. Here are a few.

29. Sharing Time What ideas do you have to share?
What questions do you have?

30. References
American Nurses Credentialing Center. (2008). Magnet recognition program manual: Recognizing nursing excellence. Silver Spring, MD: Author.
Bartelt, T., C., Ziebert, C., Sawin, K., J., Malin, S., Nugent, M., & Simpson, P. (2011). Evidence-based practice: Perceptions, skills, and activities of pediatric health care professionals. Journal of Pediatric Nursing, 26(2), doi: /j.pedn
Fineout-Overholt, E., Melnyk, B. M., & Schultz, A. (2005). Transforming health care from the inside out: Advancing evidence-based practice in the 21st century. Journal of Professional Nursing, 21(6),
Pravikoff, D. S. (2006). Mission critical: A culture of evidence-based practice and information literacy. Nursing Outlook, 54(4),
Straka, K., L., Brandt, P., & Brytus, J. (2013). Brief report: Creating a culture of evidence-based practice and nursing research in a pediatric hospital. Journal of Pediatric Nursing, 28(4), doi: /j.pedn