“Alone we can do so little; together we can do so much.” – Helen Keller
There is worldwide consensus supporting evidence-based practice (EBP) as a key element in the delivery of high quality, safe care and improving patient outcomes. Across healthcare, results from research diffuse slowly into clinical practice, and there is a consistent need to bridge this gap between research and practice.1 There are many challenges involved in closing the research-practice gap, also known as the evidence-practice gap or knowing-doing gap,2-4 and identifying the actions needed to ensure “evidence transfer” and that the best available care and treatment actually reach the patient. Evidence transfer is defined as a process that helps communicate or convey the results of research or evidence, or brings evidence to the forefront so the appropriate information gets into the hands of those who deliver healthcare.5 Frontline clinical nurse consultant (CNC) leaders at Liverpool Hospital have identified evidence transfer as a challenge to address to make a positive difference to patient care.
Liverpool Hospital is an 875-bed, public tertiary referral hospital and major trauma centre in Sydney, Australia. The hospital has a strong commitment to teaching and research across a wide range of disciplines and serves between 1.3 and 1.4 million people in the South West of Sydney. The hospital has well established, integrated processes and a governance framework in place to actively manage patient safety and quality risks, and to set, monitor and improve the performance of the organization. Clinical Nurse Consultants are advance practice nurses who play a pivotal role in these processes and provide nursing leadership that facilitates the ongoing development of clinical practice and utilization of research findings in the provision of clinical services.
Leadership provided at the point of care is increasingly recognized as critical to the acceptance and use of research evidence in practice.6 Clinical nurse consultant leaders have reported that undertaking individually led projects and implementing the findings of research was challenging and if successful, outcomes were often limited to the specialty or area in which they worked. The efficiency and productivity of such work was virtually non-existent at Liverpool Hospital as these nursing leaders reported time constraints, lack of knowledge and lack of clinical partnerships as barriers to evidence transfer. In May 2014, to overcome this systemically reported challenge, a group of 10 CNCs along with the hospital's library manager and a consumer representative came together under the leadership of a CNC who had undertaken the Joanna Briggs Institute (JBI) Evidence-based Clinical Fellowship Program. This group, the Liverpool CNC Research Group, worked collaboratively to undertake clinical leadership roles in hospital-wide evidence-based quality projects and to work toward not only bridging the evidence transfer gap but demonstrating a commitment to EBP by participating in the JBI Endorsement Program.7
The aim of the Liverpool CNC Research Group was to enhance evidence transfer through the development and sustainability of hospital-wide EBP initiatives, and to professionally develop and provide facilitated leadership opportunities for the CNCs involved. Each member underwent the JBI Practical Application of Clinical Evidence System (PACES) training, including the Getting Research into Practice framework to help identify factors underpinning gaps between practice and best practice, and strategies to overcome them. Using practice development (PD) methodology, patient safety data, the National Standards8 and available JBI resources, the group chose topics for hospital-wide quality project initiatives.
Utilizing translational research, blended with continuous practice improvement (CPI), change management techniques and PD methodologies, the group successfully undertook two projects in its first year of inception, each involving an ethics submission and a full PACES cycle including a baseline audit, implementation of targeted strategies and follow-up audits. The Excellent Practice in Communication Clinical Handover Project9 was the first, and aimed to increase staff compliance with nursing clinical handover best practice recommendations across 11 units at Liverpool Hospital. The project resulted in significantly improved outcomes across all best practice criteria and had an immediate and positive impact on clinical practice, with demonstrated sustainability. Similarly, a second project, Nutrition as Therapy,10 aimed to review and monitor staff compliance with nutrition as therapy best practice recommendations across 19 units and showed promising results, changing assessment practices at the bedside. Both projects promoted and supported the transfer and implementation of EBP through enhancing effective healthcare practices to improve patient outcomes.
Continuous practice improvement is a commonly used methodology to address problems in clinical areas and involves identifying, defining and diagnosing a problem, and developing solutions and implementing interventions. What was unique to the Liverpool Hospital, however, was the combined use of CPI and PD methodology11 to guide the implementation of targeted strategies to improve use of best practice evidence. Practice development complements numerous quality and clinical governance methods with its focus on person-centered care, knowledge translation and embedding effective workplace cultures. The nursing workforce at Liverpool Hospital had an established and widespread culture of using these principles via the Essentials of Care (EOC) Program.12 The EOC program allows healthcare teams to explore how they can improve the care or service they provide by evaluating their current workplace culture and practice, and it was a natural fit to continue to work this way while undertaking hospital-wide evidenced-based quality projects. The outcome was meaningful and collaborative engagement with frontline nurses in the contextualization of EBP, which allowed an understanding and awareness of the challenges bedside clinicians experienced tailoring to the context of care across diverse specialties, problem solving and mutual learning.
Liverpool Hospital demonstrated a commitment to evidence-based service delivery and was successfully awarded JBI endorsement in April 2016. The Liverpool CNC Research Group and undertaking hospital-wide quality initiatives have become well established across Liverpool Hospital as a method to promote evidence-based nursing practice. The group has a formalized governance structure, an established meeting schedule, as well as roll-out and sustainability plans and timelines to ensure the beneficial results of current and future projects are maintained and that the three-year JBI endorsement is renewed.
As an extension of this work and in line with the aim to enable CNCs to become independent learners and continue to contribute to evidence transfer and scholarly work in their field, Liverpool Hospital supported two CNC group members, via a scholarship, to undertake the JBI Evidence-based Clinical Fellowship Program throughout 2016, and undertake their own clinical leadership projects and develop their skills in evidence utilization and transfer. This resulted in the completion of projects on continence management and hourly rounding across multiple units at Liverpool Hospital.
The success of Liverpool Hospital's programmatic approach to EBP has extended beyond Liverpool Hospital into the remaining five hospitals within the South Western Sydney Local Health District (SWSLHD). In 2017, the JBI Evidence-based Clinical Fellowship Program was delivered using a tailored approach to 12 senior nurses across SWSLHD and involved an approach of linking CNCs to undertake the same project across multiple hospitals. Six topics, aligned to key safety and quality issues highlighted via incident data, were chosen. This process was repeated in 2018, with a further 28 senior nurses undertaking the JBI Evidence-based Clinical Fellowship program covering a further six topics, including challenging behaviors, correct patient identification and care of intravenous catheter sites, to name a few.
The Liverpool CNC Research group continues to support all clinical fellowship projects and provides governance to ensure positive results are implemented hospital wide. The program is embedded in clinical contexts where the importance of EBP skills acquisition for improving patient care is paramount. The program benefits enormously from being led by CNC clinical leaders who can target clinical microsystem teams, as the foundation of the healthcare system, integrate evidence into new and existing work, and play a fundamental role in transformation. Some CNCs who have been involved in this work have published quality projects and presented at nursing conferences as a direct result of their participation in the program. Several CNCs have implemented the methodology in their own specialty wards to promote learning, patient care and research using EBP principles. An informal evaluation of the program indicates it is achieving its aims and supporting Liverpool Hospital's vision of being Australia's safest hospital.
This body of work utilizes a collaborative approach to undertake hospital-wide quality and research projects, and has empowered CNCs by creating a forum for professional development, networking and mentoring. In addition, facility-wide nurses have been empowered to utilize the best available evidence to inform decision making at the point of care, leading to better patient outcomes. An exciting feature of the program is that it can be integrated into other disciplines, such as allied health, highlighting its pivotal role across the entire healthcare spectrum. Discussions are in progress toward planning a program that will embed EBP in a multidisciplinary, patient-centered environment and to also incorporate non-clinical services, such as education, management and corporate services.
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