Nurses’ use of the best available evidence at the point of care relies on a trifecta of practical underpinnings. First, evidence must be readily accessible to nurses and in an easy to read format (i.e. mechanical/functional).1 Second, the suite of nursing practice procedures, policies and competencies must be relevant and kept updated with the best available evidence (i.e. quality). Third, nurses in their daily practice must be willing and have the curiosity and courage to raise questions concerning their practice and the evidence base (i.e. culture2,3). For a thriving and sustainable interrelationship, these three underpinnings must be continually evaluated and nurtured. Common sense it seems, but the orchestration is rather complex and the structures, processes and outcomes that Avedis Donabedian proposed in 1966 still serve us well today when examining the infrastructure needed in order to achieve embedded evidence in a hospital setting.4 The aim of this editorial is to highlight the infrastructure that supports evidence-based practice (EBP) at University of California, San Francisco Medical Center (UCSF).
Donabedian defined structure as the resources and organization of the settings in which care occurs. The UCSF Centre for Evidence Synthesis and Implementation: a Joanna Briggs Center of Excellence is based in a hospital setting, therefore, patient and family care are naturally at the forefront of our question identification in terms of evidence synthesis and implementation work. Our quaternary 1000-bed academic medical center relies on a centralized team of clinical nurse educators, clinical nurse specialists, clinical nurse informaticists, evidence implementation specialists, clinical nurse researchers, and clinical research librarians to support, coach and train 4000 nurses. This centralized group is also known as team members of the Institute for Nursing Excellence (INEx), which is where the UCSF Centre for Evidence Synthesis and Implementation is housed. The three arms of INEx – Education and Training, Clinical Inquiry, and Practice – are the heart of evidence-based, excellent nursing care (see Figure 1). While the patient and family are at the center of our work, the members of INEx work through the nurses and other frontline staff to ensure clinicians are supported to provide consistently reliable and excellent, evidence-based care.
Maintaining our Magnet® designation keeps us focused on transformational leadership, structural empowerment, exemplary professional practice, and new knowledge and innovations. One of the cornerstones to Magnet is shared decision-making. Providing collaborative venues to discuss, evaluate and analyze evidence and our practice engages direct-care nurses and supports innovation and sustained change. Our shared decision-making core councils and other key practice committees comprise mostly direct-care nurses. The Clinical Practice Council evaluates needed practice revisions and makes recommendations for change based on the extant evidence. The Clinical InQuERI5 Council uses a variety of approaches to support all forms of clinical inquiry, including quality improvement initiatives, evidence-based practice at the point of care, primary and secondary research projects, and innovation. The Professional Development Council is charged with ensuring that nurses have access to educational and professional development opportunities, including pursuing specialty certification. These shared decision-making councils are key to any change that impacts nursing care, documentation, and/or practice and each council requires strong evidence to move projects forward. Through these structures, use of evidence to effect change at the point of care has become ingrained.
Nurses at the UCSF Medical Center are uniquely situated to create, synthesize, transfer, implement and evaluate evidence with one clear goal in mind: excellent patient and family outcomes. This shared goal is due, in part, to the processes that we have in place – or what is actually done – to support our patient and family outcomes. One example of an important process at UCSF Medical Center is the JBI programming that is run out of the UCSF JBI Centre. Our JBI Centre trains nurses to produce systematic reviews as well as how to use evidence in practice through the JBI Comprehensive Systematic Review (CSR) training and the JBI Evidence Based Clinical Fellowship program, respectively. These two programs are synergistic and build on existing processes that support and nurture evidence-based practice and innovation. Evidence synthesis may be an important starting place prior to conducting primary research, as a systematic review may reveal important gaps in the evidence. There are a number of systematic review projects underway at our Centre that are preceding primary research studies. Likewise, a JBI Clinical Fellow's implementation project is a rapid cycle small test of change that ideally results in sustained improvement, but could also create the impetus for primary research. As an example, one of the EBP Fellows at UCSF Medical Center worked on a restraint reduction small test of change in the Adult Neurological Intensive Care Unit. Given that her results were not as robust as she had hoped, the EBP Fellow collaborated with the Associate Chief Nurse Researcher and together they completed a qualitative research project that is currently in press. Both of these programs are vital to embedding evidence in practice and for sharpening direct-care nurses’ habits of thinking and questioning. Regardless of where a direct-care nurse's clinical inquiry falls on the JBI Model of Evidence-Based Healthcare,6 each element is valued and equally vital to fan the culture of clinical curiosity at our Medical Center. Daily processes shape daily work and comportment, and our JBI Centre is an important process at UCSF Medical Center in ensuring that evidence-based practice remains at the forefront to contribute to excellent patient and family outcomes.
Finally, outcomes are possible due to the structure and processes put in place. We have honed two formal programs designed to bring innovative care to the bedside by direct care nurses. Our EBP Fellows program began in 2006 and the number of participants has steadily increased over the years. As EBP fellows, direct-care nurses come with their own modestly complicated unit-based project idea, learn about evidence-based practice, and are coached in making and evaluating a small test of change over six months. For example, a project may include a device such as a neonatal resuscitation mask, product development, such as a surgical count in progress visual alert towel, or a process, such as standardizing TKO (“to keep open”) rates for central venous catheters or mobilizing hospitalized orthopedic patients on the day of surgery. To date, over 70 direct-care nurses have participated in the UCSF Medical Center EBP Program and five have participated in the JBI Clinical Fellowship program that commenced at UCSF in 2014. Internal JBI Clinical Fellows at UCSF must be former EBP Fellows, as it is expected that their Clinical Fellow implementation projects will be more complex. For example, our UCSF JBI Clinical Fellows’ projects usually involve system change, such as pediatric psychiatric staffing resource allocation or creation of a central venous catheter patency bundle that will be rolled out across the enterprise. Of note for both programs, our departmental librarians assist each fellow with searching the literature while our clinical nurse specialists and clinical nurse educators serve as clinical coaches.
Having high quality, best available evidence and transferring it for daily use at the point of care is crucial for positive patient and family outcomes. Creating a culture that relies on evidence is no accident and the structures and processes we have in place at UCSF Medical Center go far in contributing to excellence in care and outcomes.
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