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AJN, American Journal of Nursing:
doi: 10.1097/10.1097/01.NAJ.0000395243.14347.7e
Feature Articles

Evidence-Based Practice, Step by Step: Implementing an Evidence-Based Practice Change

Gallagher-Ford, Lynn MSN, RN, NE-BC; Fineout-Overholt, Ellen PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek PhD, RN, CPNP/PMHNP, FNAP, FAAN; Stillwell, Susan B. DNP, RN, CNE

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Author Information

Lynn Gallagher-Ford is assistant director of the Center for the Advancement of Evidence-Based Practice at Arizona State University in Phoenix, where Ellen Fineout-Overholt is clinical professor and director, Susan B. Stillwell is associate director, and Bernadette Mazurek Melnyk is dean and distinguished foundation professor of nursing at the College of Nursing and Health Innovation. Contact author: Lynn Gallagher-Ford, lynn.gallagher-ford@asu.edu.

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Abstract

This is the ninth article in a series from the Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every other month to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we've scheduled "Chat with the Authors" calls every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be published with May's Evidence-Based Practice, Step by Step.

In January's evidence-based practice (EBP) article, Rebecca R., our hypothetical staff nurse, Carlos A., her hospital's expert EBP mentor, and Chen M., Rebecca's nurse colleague, began to develop their plan for implementing a rapid response team (RRT) at their institution. They clearly identified the purpose of their RRT project, the key stakeholders, and the various outcomes to be measured, and they learned their internal review board's requirements for reviewing their proposal. To determine their next steps, the team consults their EBP Implementation Plan (see Figure 1 in "Following the Evidence: Planning for Sustainable Change," January). They'll be working on items in checkpoints six and seven: specifically, engaging the stakeholders, getting administrative support, and preparing for and conducting the stakeholder kick-off meeting.

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ENGAGING THE STAKEHOLDERS

Carlos, Rebecca, and Chen reach out to the key stakeholders to tell them about the RRT project by meeting with them in their offices or calling them on the phone. Carlos leads the team through a discussion of strategies to promote success in this critical step in the implementation process (see Strategies to Engage Stakeholders). One of the strategies, connect in a collaborative way, seems especially applicable to this project. Each team member is able to meet with a stakeholder in person, fill them in on the RRT project, describe the purpose of an RRT, discuss their role in the project, and answer any questions. They also tell each stakeholder about the initial project meeting to be held in a few weeks.

In anticipation of the stakeholder kick-off meeting, Carlos and the team discuss the fundamentals of preparing for an important meeting, such as how to set up an agenda, draft key documents, and conduct the meeting. They begin to discuss a time and date for the meeting. Carlos suggests that Rebecca and Chen meet with their nurse manager to update her on the project's progress and request her help in scheduling the meeting.

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SECURING ADMINISTRATIVE SUPPORT

After Rebecca updates her manager, Pat M., on the RRT project, Pat says she's impressed by the team's work to date and offers to help them move the project forward. She suggests that, since they've already invited the stakeholders to the upcoming meeting, they use e-mail to communicate the meeting's time, date, and place. As they draft this e-mail together, Pat shares the following tips to improve its effectiveness:

* communicate the essence and importance of the e-mail in the subject line

* write an e-mail that's engaging, but brief and to the point

* introduce yourself

* explain the project

* welcome the recipients to the project and/or team and invite them to the meeting

* explain why their attendance is critical

* request that they read certain materials prior to the meeting (and attach those documents to the e-mail)

* let them know whom to contact with questions

* request that they RSVP

* thank them for their participation

Before they send the e-mail (see Sample E-mail to RRT and Stakeholders), the team wants to make sure they don't miss anyone, so they review and include all of the RRT members and stakeholders. They realize that it's important to invite the manager of each of the stakeholders and disciplines represented on the RRT and ask them to also bring a staff representative to the meeting. In addition, they copy the administrative directors of the stakeholder departments on the e-mail to ensure that they're fully aware of the project.

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PREPARING FOR THE KICK-OFF MEETING

The group determines that the draft documents they'll need to prepare for the stakeholder kick-off meeting are:

* an agenda for the meeting

* the RRT protocol

* an outcomes measurement plan

* an education plan

* an implementation timeline

* a projected budget

To expedite completion of the documents, the team divides them up among themselves. Chen volunteers to draft the RRT protocol and outcomes measurement plan. Carlos assures her that he'll guide her through each step. Rebecca decides to partner with her unit educator to draft the education plan. Carlos agrees to take the lead in drafting the meeting agenda, implementation timeline, and projected budget, but says that since this is a great learning opportunity, he wants Rebecca and Chen to be part of the drafting process.

Drafting documents. Carlos tells the team that the purpose of a draft is to initiate discussion and give the stakeholders an opportunity to have input into the final product. All feedback is a positive sign of the stakeholders' involvement, he says, and shouldn't be perceived as criticism. Carlos also offers to look for any templates from other EBP projects that may be helpful in drafting the documents. He tells Rebecca and Chen that he's confident they'll do a great job and shares his excitement at how the team has progressed in planning an EBP practice change.

RRT protocol. Chen starts to draft the RRT protocol using one of the hospital's protocols as a template for the format, as well as definitions and examples of protocols, policies, and procedures from other organizations and the literature. She returns to the articles from the team's original literature search (see "Critical Appraisal of the Evidence: Part I," July 2010) to see if there is information, previously appraised, that will be helpful in this current step in the process. She recalls that the team had set aside some articles because they didn't directly answer the PICOT question about whether to implement an RRT, but they did have valuable information on how to implement an RRT. In reviewing these articles, Chen selects one that's a review of the literature, though not a systematic review, that includes many examples of RRT membership rosters and protocols used in other hospitals, and which will be helpful in drafting her RRT protocol document.1 Chen includes this expert opinion article because the information it contains is consistent with the higher-level evidence already being used in the project. Using both higher and lower levels of evidence, when appropriate, allows the team to use the best information available in formulating their RRT protocol.

As she writes, Chen discovers that their hospital's protocols and other practice documents don't include a section on supporting evidence. Knowing that evidence is critically important to the RRT protocol, she discusses this with the clinical practice council representative from her unit who advises her to add the section to her draft document. He promises to present this issue at the next council meeting and obtain the council's approval to add an evidence section to all future practice documents. Chen reviews the finished product before she submits it for the team's review (see RRT Protocol Draft for Review1–10).

Outcomes measurement plan. Based on the appraised evidence and the many discussions Rebecca and Chen have had about it, Chen drafts a document that lists the outcomes the team will measure to demonstrate the success of their project, where they'll obtain this information, and who will gather it (see Table 1). In drafting this plan, Chen realizes that they don't have all the information they need, and she's concerned that they're not ready to move forward with the stakeholder kick-off meeting. But when Chen calls Carlos and shares her concern, Carlos reminds her that the document is a draft and that the required information will be addressed at the meeting.

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Table 1
Table 1
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Education plan. Rebecca reaches out to Susan B., the clinical educator on her unit, and requests her help in drafting the education plan. Susan tells Rebecca how much she enjoys the opportunity to work collaboratively with staff nurses on education projects and how happy she is to see an EBP project being implemented. Rebecca shares her RRT project folder (containing all the information relative to the project) with Susan, focusing on the education about the project she thinks the staff will need. Susan commends the team for its efforts, as a good deal of the necessary work is already done. She asks Rebecca to clarify both the ultimate goal of the project and what's most important to the team about its rollout on the unit. Rebecca thoughtfully responds that the ultimate goal is to ensure that patients receive the best care possible. What's most important about its rollout is that the staff sees the value of an RRT to the patients and its positive impact on their own workload. She adds that it's important to her that the project be conducted in a way that feels positive to the staff as they work toward sustainable changes in their practices.

Susan and Rebecca discuss which clinicians will need education on the RRT. They plan to use a variety of mechanisms, including in-services, e-mails, newsletters, and flyers. From their conversation, Susan agrees to draft an education plan using a template she developed for this purpose. The template prompts her to put in key elements for planning an education program: learner objectives, key content, methodology, faculty, materials, time frame, and room location. Susan fills the template with information Rebecca has given her, adding information she knows already from her experience as an educator. When Rebecca and Susan meet to review the plan, Rebecca is amazed to see how their earlier conversation has been transformed into a comprehensive document (see the Education Plan for RRT Implementation at http://links.lww.com/AJN/A19).

Agenda and timeline. The team meets to draft the meeting agenda, implementation timeline, and budget. Carlos explains the purposes of a meeting agenda: to serve as a guide for the participants and to promote productivity and efficiency. They draft an agenda that includes the key issues to be shared with the stakeholders as well as time for questions, feedback, and discussion (see the Rapid Response Team Kick-off Meeting Agenda at http://links.lww.com/AJN/A20).

Carlos describes how the timeline creates a structure to guide the project (see Table 2 at http://links.lww.com/AJN/A21). The team further discusses how it can maintain the project's momentum by keeping it moving forward while at the same time accommodate unexpected delays or resistance. There are a few items on the timeline that Carlos thinks may be underestimated—for example, the team may need more than a month to meet with other departments because of already heavily scheduled calendars—but he decides to let it stand as drafted, knowing that it's a guide and can be adjusted as the need arises.

Budget. Carlos discusses the budget with the team. Rebecca shares a list of what she thinks they'll need for the project and the team decides to put this information into a table format so they can more easily identify any missing information. Before they construct the table, they walk through an imaginary RRT call to be sure they've thought of all the budget implications of the project. They realize they didn't include the cost of each employee attending an education session, so they add that figure to the budget. They also realize that they're missing hourly pay rates for the different types of employees involved. Carlos tells Rebecca that he'll work with the Human Resources Department to obtain this information before the meeting so they can complete the budget (see Table 3).

Table 3
Table 3
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REVIEWING THEIR WORK

The next time they meet, the EBP team reviews the agenda for the meeting and the documents they'll be presenting. The clerical person on Rebecca and Chen's floor (sometimes called the unit secretary) has kept a record of who's attending the meeting and the team is pleased that most of the stakeholders are coming. Carlos informs the team that he received notification that their internal review board submission has been approved. They're excited to check that step off on their EBP Implementation Plan.

Carlos suggests that they discuss the kick-off meeting in detail and brainstorm how to prepare for any negative responses to their project that might occur. Rebecca and Chen remark that they've never considered that someone might not like the idea of an RRT. Carlos says he's not surprised; often the passion that builds around an EBP project and the hard work put into it precludes taking time to think about "why not." The team talks about the importance of stopping occasionally during any project to assess the environment and participants, recognizing that people often have different perspectives and that everyone may not support a change. Carlos reminds the team that people may simply resist changing the routine, and that this can lead to the sabotage of a new idea. As they explore this possible resistance, Rebecca shares her concern that with everyone in the hospital so busy, adding something new may be too stressful for some people. Carlos tells Rebecca and Chen that helping project participants realize they'll be doing the same thing they've been doing, just in a more efficient and effective way, is generally successful in helping them accept a new process. He reminds them that many of the people on the RRT are the same people who currently take care of patients if they code or are admitted to the ICU; however, with the RRT protocol, they'll be intervening earlier to improve patients' outcomes. The team feels confident that, if needed, they can use this approach at the kick-off meeting.

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CONDUCTING THE KICK-OFF MEETING

Rebecca and Chen are both nervous and excited about the meeting. Carlos has made sure they're well prepared by helping them set up the meeting room, computer, PowerPoint presentation, and handout packets containing the agenda and draft documents. The team is ready, and they've placed themselves at the head of the table so they can be visible and accessible. As the invitees arrive, they welcome each one individually, thanking them for participating in this important meeting. The team makes sure that the meeting is guided by the agenda and moves along through the presentation of information to thoughtful questions and a lively discussion.

Join the EBP team next time as they launch the RRT project and tackle the real-world issues of project implementation.

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REFERENCE

1. Choo CL, et al. Rapid response team: a proactive strategy in managing haemodynamically unstable adult patients in the acute care hospitals. Singapore Nursing Journal 2009; 36(4);17–22.

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© 2011 Lippincott Williams & Wilkins, Inc.

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