This month, we focus on an educational program designed to equip nursing staff with evidence-based practice (EBP) skills and knowledge, with the goal of improving and changing practice based on the best available evidence. In the following narrative, Elisa Jang describes the Evidence-Based Practice and Research Fellowship Program, which spans 15 months and is available to her institution's nursing staff, who apply with a project idea they'd like to implement on their unit. Jang manages this program, which is modeled on the University of Iowa Hospitals and Clinics Evidence-Based Practice Staff Nurse Internship program. She details how she and her colleagues developed the program and what it entails, as well as the program deliverables. She also identifies implementation strategies that have contributed to the success of this program. We then comment on how these strategies align with the best implementation strategies reported in the literature.—Sharon J. Tucker and Lynn Gallagher-Ford
Our institution, a community hospital located in a small city, has two campuses: one has a 132-bed hospital and the other a 50-bed hospital. Although categorized as a community hospital, our institution also offers advanced services, such as an ED with a level 2 trauma center, cardiac and neurologic surgery, a chest pain and stroke center, a cancer center, and a labor and delivery department with a neonatal ICU. Nursing staff mix includes RNs (a little more than 80% have bachelor of science in nursing [BSN] degrees currently), monitor technicians, certified nursing assistants, and unit clerks.
As the clinical nurse specialist (CNS) for critical care services, I was approached in early 2005 by the chief nursing officer (CNO), who asked me to gain a better understanding of the EBP movement and assess our organization's status. I found significant gaps in clinical practice, as evidenced by poor outcomes and quality reports that were not meeting benchmarks. There was also a knowledge gap regarding the standards of integrating evidence into practice. A survey was developed and sent to all in-patient RNs—approximately 35% of whom were BSN-prepared at that time—to gain a more formal assessment of this gap. The survey revealed that 61% of RNs didn't know what “EBP” meant, 67% didn't believe all nurses should be required to apply research to their clinical practice, 58% said they wouldn't immediately be willing to change their practice if the available evidence showed a specific practice was no longer recommended, and 45% didn't know if the hospital utilized research findings in the development of policies and procedures. Working together with our institution's other CNSs and the clinical educator, I investigated whether our policies and procedures were evidence based and found they didn't include supportive data or references. In addition, as I tried to identify the type of EBP resources available to our staff, I discovered a resource gap: our institution only had two small medical libraries—one on each campus—that contained uncatalogued hard copy journals.
We presented our findings, as well as evidence in support of EBP fellowship programs, to our institution's leadership.
DEVELOPMENT OF THE FELLOWSHIP PROGRAM
Our institution formed the EBP and Research Council in 2006 with the goal of creating a multidisciplinary team to promote patient care based on best practice evidence. I pitched the idea to the CNO as a way to establish standardization and gain momentum as we began our EBP journey. The council consisted mostly of nurses, with interprofessional participation from pharmacy, rehabilitation services, and respiratory therapy. The group was charged with addressing the research–practice gap and accelerating the translation of evidence into practice. It did so by developing and implementing the Evidence-Based Practice and Research Fellowship Program. This program provides the structure and process to translate new knowledge and innovation into improved clinical practice at our institution.
Nurses apply to the program to develop, implement, and evaluate a clinically relevant project or to conduct a research study in their department. Then they develop clinical questions in PICO-T (population, intervention, comparison, outcome, and, if appropriate, time) format based on identified gaps in practice in their respective units. The 15-month program is divided into three parts: (1) six months of EBP and project management classes that provide participants with the foundational knowledge and skills they need to implement an EBP initiative; (2) five months of intervention implementation and data collection and analysis; and (3) four months of disseminating this information internally and externally. (Originally, this was a 12-month program, encompassing classes and implementation. When the formal dissemination plan was integrated, the program was lengthened to 15 months.)
The EBP and Research Council sought approval from the nursing directors and CNO for a budget to support 144 hours for one RN from each unit to participate in the program each year (there is enough flexibility in the unit budgets to accommodate the participants' involvement in this program for the additional three months). The 144 hours include 48 hours dedicated to classes (six eight-hour, monthly classes); 60 hours to implement the practice change and for data collection, entry, and analysis (12 hours per month for five months); and 36 hours to disseminate the plan, which includes time to work on internal presentations and articles, the submission of abstracts, and external poster presentations or publications.
The council members developed an application process, including criteria for determining qualification for acceptance into the program. Applicants needed at least two years of clinical experience, to be on their current unit for at least a year, and to have at least a 0.5 full-time equivalent status. They couldn't have a disciplinary action pending against them or be on a performance improvement plan. They also had to obtain a letter of professional recommendation and provide a written description of the clinical question they wanted to explore.
As the program manager and primary instructor, I developed the class curriculum, which covers a variety of topics, including searching strategies, research design, critical appraisal, levels of evidence, project management, implementation science, and adult learning principles and pedagogy. We used the Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care framework to guide the participants through the steps of the EBP process (see https://uihc.org/iowa-model-revised-evidence-based-practice-promote-excellence-health-care). According to the Iowa Model, participants follow one of two paths: if there is strong evidence to support the answer to the PICO-T question, they implement an EBP initiative; if there isn't sufficient evidence to implement a practice change, they develop a research study to create new knowledge.1
STRATEGY AND IMPLEMENTATION PLAN
Approximately six to eight months elapsed between the program's inception and full implementation. Marketing the program involved multimodal communication channels, including bulletin board flyers, e-mail messages, organizational newsletter announcements, and staff meeting discussions. Informational meetings were also held, enabling the staff to learn more about the program and ask questions. RNs were invited to submit applications detailing how they met the fellowship program criteria and to describe their proposed clinical inquiry or practice issue. After applications were submitted, council members conducted a blinded review of the projects. Potential candidates were asked to attend a panel interview with members of the EBP and Research Council, who developed standardized evaluation criteria to assist in deciding which participants were accepted into the program.
We arranged for additional resources and support to help participants succeed in their projects. CNSs were recruited to serve as clinical mentors and paired with each participant, helping to analyze projects and provide guidance. Additionally, clinical managers provided support by ensuring participants were exempt from patient care on class days. The 12 hours participants spent each month implementing their projects was in addition to their full-time equivalent status. Similarly, participants disseminated their work when they were not working on the unit. Buy-in was obtained from the nursing directors by emphasizing the need for improved patient outcomes and the cost–benefit ratio of nurses from each department implementing an EBP initiative focused on improvements in clinical practice, patient outcomes, and system and organizational outcomes.
Before the program started, our institution secured contracts for journal subscriptions, and an online library platform was developed to allow participants to access evidence. Funding for the online library was budgeted under clinical support services. Our team started with approximately two different bibliographic databases, and additional subscriptions and databases have since been added. The medical librarian was asked to provide additional support, searching for and obtaining articles our organization didn't have access to.
There were no nurse scientists at our small community hospital. For this reason, we entered into a formal contract with a local tertiary hospital's nurse scientists, who serve as consultants to participants in the fellowship program. We also recruited a statistician to help with statistical analysis. Clinical managers and directors are also involved: they're required to attend the last hour of the last three classes, when each participant provides a briefing of what they've accomplished and explains if additional resources are needed.
Multiple strategies are used to keep the participants engaged throughout the program. Each class follows the same format and starts with a didactic lecture on the day's focus. The participants are then provided with time to put their knowledge and skills into practice. For example, the first class focuses on searching strategies. Information is provided on ways to search the literature, including various search tips and strategies for using Boolean operators and formatting clinical inquiries into PICO-T questions. Use of the online library platform is also reviewed. Then the participants are provided with time to put the lecture into practice by developing their PICO-T questions, generating word lists, and searching for articles. This method of teaching supports adult learning principles and has helped to show the participants how to put EBP knowledge and skills into practice.
Participants in the fellowship program meet with their CNS mentor and the program manager each month, providing updates on the project's progress. Each participant also forms a “change team.” Based on Roger's diffusion of innovation theory, this team consists of opinion leaders, change champions, and a core group who will adopt the innovation before most others in a given system.2 This team helps the participant implement the EBP initiative and develop into a transformational leader who “engages with others and creates a connection that raises the level of motivation and morality of both the leader and the follower.”3
The fellowship program is ongoing, with a new cohort recruited every year from all nursing units within our institution's patient care service division. Approximately five to 10 participants apply each year. The total number accepted varies, depending on the number of mentors we have available to pair with the participants. The fellowship program is now overseen by the Department of Nursing Education and Clinical Practice, but the EBP and Research Council is still very closely involved in the selection process and the creation of clinical inquiry ideas.
The outcomes of implementing EBP are often difficult to track. Each participant in the fellowship program is required to select outcomes from the following three categories: clinical practice or process, patients, and system or organization. These outcomes were selected so that participants could show how their EBP projects demonstrate a return on investment and an improvement in clinical outcomes. A total of 18 EBP projects and six research studies have been completed to date. The outcomes of selected projects are detailed in Table 1.
Each participant develops and executes a formal dissemination plan. Internal dissemination includes an oral presentation at the participant's unit staff meeting, as well as during shared governance and management team meetings. Participants also submit an article about their project and results to EBP Newsletter, our organization's quarterly, internal newsletter. We often use these internal dissemination events as opportunities to celebrate the participants' successes and to recognize their hard work in front of their peers. External dissemination includes submission of an abstract to our organization's regional EBP and research conference. Participants are also strongly encouraged to submit an abstract for a poster or podium presentation to their professional association's meeting and local or national conferences. If their abstract is accepted, the EBP and Research Council funds the conference registration fee for the program participant. If participants are interested in submitting a manuscript for publication, they can work with either our nurse scientist consultants or the program manager, who provide support and guidance.
To date, seven project participants have had their abstracts accepted for presentation at local and national conferences, including a Sigma Theta Tau chapter event, the American Nurses Credentialing Center's National Magnet Conference, the American Association of Critical-Care Nurses' National Teaching Institute and Critical Care Exposition, Stanford University's Healthcare Research and Education Conference, the annual meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation, and the national conferences of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses. In fact, the poster presentation at the AWHONN conference won first place!
During the conceptualization of the fellowship program, I realized that access to EBP resources would be a barrier at our institution, with its limited medical library facilities and resources. Participants in the program needed access to bibliographic databases to search for the best available evidence. I researched different options, looking for systems that had features such as unlimited access, an intuitive interface, and variety in their offerings to support our organization's clinical specialties. Members of the EBP and Research Council also participated in this process. Initially, we received funding for two database subscriptions—CINAHL and ProQuest—and our intuition now provides access to 15 databases.
Even though the interventions implemented by fellowship program participants have made an impact on patient outcomes, there has been a lack of measurement focused on the EBP knowledge and skills gained by these participants. We therefore intend for future outcomes plans to include pre- and postmeasurements of EBP confidence, knowledge, and competence.
Nurses have a responsibility to promote EBP among their colleagues and to use it in daily clinical practice. Clinicians of all disciplines are uniquely positioned at all levels of practice to ask questions, engage in the advancement of clinical practice, and achieve the best possible patient outcomes in an evolving, complex health care environment. EBP can be embraced by anyone who participates in patient care and is interested in finding the best solutions to care for their patients.
Jang's narrative about this EBP educational project includes recognition that the research-to-practice gap is a result of not one but multiple contributing factors and that implementation success will require the use of multiple strategies. The rollout of the Evidence-Based Practice and Research Fellowship Program was focused on specific implementation strategies that addressed contributing factors: organizational culture, policies that didn't support the use of research, and insufficient knowledge at the bedside regarding how to apply research findings. Importantly, Jang also used data to assess the need for this program, comparing poor clinical outcomes with benchmarks and surveying the staff, which revealed significant knowledge gaps regarding EBP and a lack of research-based policies. These data were presented to leadership, along with evidence in support of EBP fellowship programs, securing funding to create and develop this 15-month program. Data collection was also built into each fellow's project.
The fellowship program was built on evidence, and then multiple implementation strategies were used to engage the fellows in the learning process, including didactic content delivery; allowing for time to participate in the fellowship activities; providing skill development (with the assistance of a librarian) to perform literature searches; and helping to develop a PICO-T question. For each project, specific implementation strategies were stressed, including convening a team of stakeholders and selecting targeted patient outcomes. Ongoing strategies to maintain fellows' engagement during the program included scheduling regular meetings with the fellowship program leader and promoting the dissemination of outcomes to both internal and external audiences. Most impressive for Jang's evidence-based program are the patient outcomes reported for the fellows' projects.