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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000405063.97774.0e
Feature Articles

Evidence-Based Practice, Step by Step: Sustaining Evidence-Based Practice Through Organizational Policies and an Innovative Model

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

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Author Information

Bernadette Mazurek Melnyk is associate vice president for health promotion, university chief wellness officer, and dean of The Ohio State University College of Nursing in Columbus, where Lynn Gallagher-Ford is director of Transdisciplinary Evidence-Based Practice and Clinical Innovation. Ellen Fineout-Overholt is dean of Professional Studies and chair of the Department of Nursing at East Texas Baptist University in Marshall, TX. Susan B. Stillwell is clinical professor and associate director of the Center for the Advancement of Evidence-Based Practice at Arizona State University in Phoenix. At the time this article was written, Bernadette Mazurek Melnyk was dean and distinguished foundation professor of nursing in the College of Nursing and Health Innovation at Arizona State University, where Ellen Fineout-Overholt was clinical professor and director, and Lynn Gallagher-Ford was clinical assistant professor and assistant director, of the Center for the Advancement of Evidence-Based Practice. Contact author: Bernadette Mazurek Melnyk, melnyk.15@osu.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise.

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Abstract

The team adopts the Advancing Research and Clinical Practice Through Close Collaboration model.

This is the 12th and last 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 it's 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 complete EBP series is available as a collection on our Web site; go to www.ajnonline.com and click on Collections.

In July's evidence-based practice (EBP) article, Rebecca R., Carlos A., and Chen M. evaluated the outcomes of their rapid response team (RRT) implementation project. Their findings indicated that a significant decrease in one outcome, code rates outside the ICU, had occurred after implementation of the RRT. This promising finding, together with many other considerations—such as organizational readiness; clinician willingness; and a judicious weighing of all the costs, benefits, and outcomes—encouraged the EBP team to continue with plans to roll out the RRT protocol throughout the entire hospital system. They also began to work on presentations and publications about the project so that others could learn from their experience and implement similar interventions to improve patient outcomes.

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USING EVIDENCE TO INFORM ORGANIZATIONAL POLICY

Because Rebecca, Carlos, and Chen are concerned about whether the implementation of an RRT can be sustained over time in their hospital, they want to take the necessary steps to create a hospital-wide RRT policy. Therefore, they make an appointment with their hospital's director of policies and procedures, Maria P., to share the outcomes data they've gathered from their project and to discuss the project's success so far. Maria is impressed by the rigor of the team's sequential EBP process and the systematic way in which they've gathered the outcomes data. She reminds them that the measurement of outcomes (internal evidence) plus rigorous research (external evidence) result in the best evidence-based organizational policies to guide the highest quality of care in health care institutions.

Maria volunteers to assist the team in writing a new evidence-based policy to support having an RRT in their hospital. She suggests that each recommendation in the policy be supported by evidence. Maria explains that once the policy is written, it needs to be approved by the hospital-wide policy committee, representing all of the health disciplines. Maria emphasizes that transdisciplinary health care professionals and administrators should routinely be involved when planning and implementing evidenced-based organizational policies. She also reminds the EBP team that translating evidence and evidence-based organizational policies into sustainable routine clinical practices remains a major challenge for health care systems.

The new RRT policy written by Rebecca, Carlos, and Chen with Maria's help is approved by the hospital-wide policy committee within three months. Now the challenge for the team is to work with clinicians across the hospital system to implement it. The EBP team schedules a series of presentations throughout the hospital to introduce the new RRT policy. They rotate the days and times of this in-service to capture as many direct care clinicians as possible. To ensure that all clinicians are educated on the new policy, a database is created to track in-service attendees, and each hospital unit is asked to appoint a volunteer to deliver the presentation to any clinicians who missed it. Posters are created and buttons designed as visual triggers to remind staff to implement the new policy.

Throughout this process, the EBP team learned that dissemination of evidence alone doesn't typically lead clinicians to make a sustainable change to EBP, and they were impressed by how important it was to have unit-based champions reinforce the new policy.1 They also learned that it's critical to have an organizational culture that supports EBP (such as evidence-based decision making integrated into performance expectations, up-to-date resources and tools, ongoing EBP knowledge and skills-building workshops, and EBP mentors at the point of care) in order for clinicians to consistently deliver evidence-based care.2

Since the process they followed worked so well, the team believes that their hospital needs to adopt a model to guide and reinforce the creation of a culture to sustain the EBP approach they had initiated through this project. They review several EBP process and system integration models and decide to adopt the Advancing Research and Clinical Practice Through Close Collaboration (ARCC) model because its key strategy to sustain evidence-based care is the presence of an EBP mentor (a clinician with advanced knowledge of EBP, mentorship, and individual as well as organizational change). With Carlos's success as an expert EBP mentor, and the mentorship model working so well, they believe that developing a cadre of EBP mentors system-wide is key to the ongoing implementation and sustainability of EBP in their organization.

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SUSTAINING AN EBP CULTURE WITH THE ARCC MODEL

In reviewing the ARCC model, the EBP team finds that its aim is to provide hospitals and health care systems with an organized conceptual framework to guide system-wide implementation and sustainability of EBP for the purpose of improving quality of care and patient outcomes. In addition, this model can be used to achieve a "high reliability" organization (one that delivers safe and high-quality care), decrease costs, and improve clinicians' job satisfaction. Four assumptions are basic to the ARCC model3:

* Both barriers to and facilitators of EBP exist for individuals and within health care systems.

* Barriers to EBP must be removed or mitigated and facilitators put in place in order for individuals and health care systems to implement EBP as a standard of care.

* For clinicians to change their practices to be evidence based, both their beliefs about the value of EBP and their confidence in their ability to implement it must be strengthened.

* An EBP culture that includes EBP mentors is necessary in order to advance and sustain EBP in individuals and health care systems.

The first step in the ARCC model is to assess the organization's culture and readiness for EBP (see Figure 1). From that assessment, the strengths and limitations of implementing EBP within the organization can be identified. The key implementation strategy in the ARCC model is the development of a cadre of EBP mentors, who are typically advanced practice nurses or clinicians with in-depth knowledge of and skills in EBP and in individual behavior change and organizational culture change. These individuals, whether expert system-wide mentors, advanced practice mentors, or peer mentors, are focused on helping point-of-care clinicians to use and sustain EBP and to conduct EBP implementation, quality improvement, and outcomes management projects. When clinicians work with EBP mentors, their beliefs about the value of EBP and their ability to implement it increase, and this is followed by a greater achievement of evidence-based care.4 The ARCC model contends that greater implementation of EBP results in higher job satisfaction, lower turnover rate, and better patient outcomes. A series of studies now support the empirical relationships in the ARCC model.4–8

Figure 1
Figure 1
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The ARCC model has been and continues to be implemented in hospitals and health care systems across the country with excellent results in quality of care and patient outcomes. Valid and reliable instruments, such as the EBP Beliefs and EBP Implementation scales,6 are used to measure key constructs in the model and, together with organizational culture and readiness for EBP, help to determine the model's effectiveness.6

The EBP team discusses how all the elements of the ARCC model are an excellent fit for their organization. They decide to make a recommendation to the Shared Governance Steering Committee that this model be adopted, not only for the nursing department, but for all disciplines throughout the organization.

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THE EBP JOURNEY HAS JUST BEGUN

This series presented a case involving a hypothetical medical–surgical nurse and her colleagues to illustrate how EBP can be successfully implemented to improve key patient outcomes. It's important that the process start with an ongoing spirit of inquiry, and that nurses always question the evidence behind the care we provide and never settle for the status quo. Never forget that it only takes one passionate, committed person to spearhead a team vision to improve care for patients and their families. It also takes persistence through the "character builders" that are sure to appear as the vision comes to fruition.

Although the EBP team has successfully completed their RRT implementation project and its incorporation as a hospital-wide policy, their EBP journey has just begun. In fact, only days after the project's completion, Rebecca asked Carlos another great PICOT question: "In critically ill patients, how does early ambulation compared with delayed ambulation affect ventilator-associated pneumonia in the ICU?" Carlos looked at her and replied, as a great mentor does, "I will help you search for the evidence and we will find the answer to your question—because EBP, not practices steeped in tradition, is the only way we do it here!"

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REFERENCES

1. Melnyk BM, Wiliamson KM. Using evidence-based practice to enhance organizational policies, healthcare quality, and patient outcomes. In: Hinshaw AS, Grady PA, editors. Shaping health policy through nursing research. New York: Springer Publishing Company; 2011. p. 87-98.

2. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2011.

3. Melnyk BM, Fineout-Overholt E. ARCC (Advancing Research and Clinical practice through close Collaboration): a model for system-wide implementation and sustainability of evidence-based practice. In: Rycroft-Malone J, Bucknall T, editors. Models and frameworks for implementing evidence-based practice: linking evidence to action. Oxford; Ames, IA: Wiley-Blackwell; Sigma Theta Tau; 2010. p. 169-84.

4. Melnyk BM, et al. Nurses' perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: implications for accelerating the paradigm shift. Worldviews Evid Based Nurs 2004;1(3):185-93.

5. Levin RF, et al. Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: a pilot test of the advancing research and clinical practice through close collaboration model. Nurs Adm Q 2011;35(1):21-33.

6. Melnyk BM, et al. The evidence-based practice beliefs and implementation scales: psychometric properties of two new instruments. Worldviews Evid Based Nurs 2008;5(4):208-16.

7. Melnyk BM, et al. Correlates among cognitive beliefs, EBP implementation, organizational culture, cohesion and job satisfaction in evidence-based practice mentors from a community hospital system. Nurs Outlook 2010;58(6):301-8.

8. Wallen GR, et al. Implementing evidence-based practice: effectiveness of a structured multifaceted mentorship programme. J Adv Nurs 2010;66(12):2761-71.

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© 2011 Lippincott Williams & Wilkins, Inc.

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