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Evidence-Based Practice Change Champion Program Improves Quality Care

Cullen, Laura DNP, RN, FAAN; Hanrahan, Kirsten DNP, ARNP, CPNP-PC, FAAN; Farrington, Michele BSN, RN-BC; Anderson, Robert DNP, ARNP, CCRN; Dimmer, Emily BSN, RN, CMSRN; Miner, Rebecca DNP, RN-BC, CNML; Suchan, Taylor BSN, RN, CMSRN; Rod, Emily MSN, RN, CMSRN

Author Information
JONA: The Journal of Nursing Administration: March 2020 - Volume 50 - Issue 3 - p 128-134
doi: 10.1097/NNA.0000000000000856
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Abstract

Nurses value providing quality care. Programs are needed that assist point-of-care nurses to lead evidence-based practice (EBP) improvements. Training and mentorship are important to facilitate nurses leading interprofessional teams, implementing EBP changes, and demonstrating an impact. Organizations can meet nurses' professional development needs by establishing programs with dedicated mentors to achieve organizational priorities for quality care.

Background

Nurses have responsibility for providing, leading, and sustaining evidence-based healthcare. Therefore, multiple opportunities are needed to promote EBP learning across nurses' career continuum. Programs should be designed to provide tools and support for point-of-care nurses to lead EBP in their institutions.1

Leading EBP requires nurses to function as effective change agents. Diverse change agent roles may positively influence EBP adoption.2,3 An EBP Change Champion (CC) is “a charismatic individual who throws his or her weight behind an innovation, thus overcoming indifference or resistance that the new idea may provoke in an organization … [and] can play an important role in boosting a new idea.”4 Research indicates champions may be effective,5 yet few studies describe the role.6-9 Clarity is emerging around how to use various change agent roles.2,10-12 The EBP CC role was operationalized to provide point-of-care nurses with the skills and tools to lead EBP.13 The focus was local, so nurses could influence peers and impact key clinical outcomes.6,14

Program Overview/Description

An EBP CC program was created to complement a comprehensive set of EBP training programs for nurses. The program was developed by EBP experts in a large academic medical center in the Midwest with a strong EBP culture and locally developed EBP resources. EBP experts identified an opportunity to expand formal support for point-of-care nurses in EBP. This innovative program fit with existing EBP training opportunities, resources, and funding.13,15-17 A unique focus of this program was to expand application of EBP and implementation science in a program complementary to existing opportunities that directly address quality priorities.

Program Purpose

The EBP CC program was designed to provide professional development, operationalize the EBP CC role, and improve outcomes. Program objectives were designed to engage point-of-care clinicians to lead teams who can make implementation and evaluation actionable. Objectives were to:

  • assist point-of-care nurses to function as change agents applying EBP in daily practice;
  • expand infrastructure support for local nurse leaders serving as change agents;
  • foster professional growth of point-of-care nurses and interprofessional teams; and
  • promote nursing retention.

Topics were selected using a “top-down” approach addressing organizational priorities, national standards, or the National Database of Nursing Quality Indicators®.18 Clinical topics (eg, hospital-acquired events) were preselected from core indicators by nursing quality leaders and confirmed by nurse executives. Unit or clinic managers worked collaboratively within their clinical division (eg, ICU, pediatrics, medical-surgical) to determine distribution of available spots in the program. Nurse managers (NMs) from participating areas matched the selected topic with EBP CC interests to nominate applicants. A leader from the same clinical area served as a nurse leader partner (NLP). The NLP was selected from among the NM, Assistant NM, and others in leadership positions on the participating units.

Program Content

Program prerequisites included an online module reviewing EBP and 3 articles so participants had common baseline understanding of implementation,19 the EBP CC role,20 and a topic-specific EBP CC example.21 Program content (Table 1) provided background on the Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care (Iowa Model),22 the EBP model that had been previously adopted by the organization. Background content was covered so the EBP CC could jump-start work in the middle of the EBP process with local implementation and evaluation using existing tools.13 Action plans were created to ensure immediate progress.

Table 1
Table 1:
EBP CC Program Content

Participants, Teams, and Roles

Each EBP CC (n = 21) partnered with an NLP (n = 19) and topic expert (1 per quality indicator) to function as a core group with support from the NM.23 EBP experts provided training, facilitation, and resources during the training and addressed needs or requests throughout project work.

EBP Change Champions

NMs selected unit- or clinic-based emerging point-of-care nurse leaders using criteria that included evidence-based characteristics (Table 2). Point-of-care nurses with respected clinical expertise, commitment to high-quality care, strong communication skills, and positive, persuasive peer influence were selected. The EBP CC focused on key steps in the Iowa Model that promote EBP, including adapting the practice to fit the needs of their patients and team workflow. The role was operationalized to facilitate positive leadership and peer influence. Select EBP CC role elements include:

Table 2
Table 2:
Criteria for Selection
  • Assist with adapting practice recommendations and tailor implementation plan and materials to fit local unit/clinic;
  • Share knowledge, evidence, rationale, and resources with colleagues at the point-of-care;
  • Train and demonstrate skills so colleagues know how to adopt the EBP change;
  • Use and role model the practice change;
  • Provide just-in-time encouragement and troubleshooting at point-of-care;
  • Make equipment easily accessible;
  • Provide persistent, continuous reinforcement of new practices;
  • Communicate in ways that are personal, persuasive, credible, respectful, and highly visible;
  • Remain positive and responsive to colleagues;
  • Report to team leaders on implementation issues and suggest revisions;
  • Promote midstream corrections to maintain essential elements of the practice recommendations and to keep forward momentum; and
  • Set incremental project goals, monitor data, and provide feedback.

Nurse Leader Partners

Many of the NLPs were also novices to EBP and therefore participated in all elements of the training. NLPs were paired with EBP CCs from the same clinical area. The NLP addressed local needs, scheduling and coordinating the work and internal dissemination. The NLP role focused on facilitating EBP and addressing barriers.24-26 Unit leaders, including the NLP and NM, supported adapting the practice change and focused on implementation planning and sustainment of EBP changes. These leaders' actions were to:

  • Facilitate the belief that the change is needed;
  • Advise or seek guidance on the steps in the EBP process;
  • Round to identify current practice patterns, troubleshoot, assess learning needs, and reinforce priority evidence-based care;
  • Advocate and budget for access and use of resources for EBP; and
  • Celebrate the team's success.

Topic Experts

Content experts knowledgeable about the evidence, related institutional policies, quality data, and EBP methods were departmental clinical nurse specialists and chairs of topic-specific organizational committees. Topic experts served as faculty, selected a prerequisite topic reading, led topic-specific concurrent sessions, discussed relevant evidence, and guided development of the practice change and action plans. Topic experts later served as EBP facilitators available to field questions, offer support, and encourage participation and reporting within the applicable committees.2 Their focus was practice integration and ongoing adoption. Their role was to:

  • Identify priority topics and collaborate in topic selection, prior to the training;
  • Partner with unit/clinic leaders and the interprofessional team.
  • Advise on the steps in the EBP process; and
  • Provide consultation for the topic and serve as a liaison working within the organization;
  • Manage continual reporting of progress;

Both the NLP and the topic expert also used common strategies to facilitate the work of the EBP CC. Among these strategies are: 1) promote interprofessional collaboration to create an open, supportive, and trusting environment; 2) provide or guide the EBP CC through project management; 3) anticipate and proactively address barriers to implementation of EBP from a practical perspective from the point-of-care; and 4) advise on the development of an implementation plan and resources for implementation tailored to the local setting.

Case Exemplar

An EBP CC-NLP pair recognized patients on their 32-bed acute, orthopedic-urology postsurgical unit were at risk of catheter-associated urinary tract infections (CAUTIs). They focused on engaging and expanding the role of nursing assistants (NAs) in implementing EBP recommendations. Because NAs are responsible for much of the care and maintenance of urinary catheters, they were critical stakeholders for CAUTI prevention.

Synthesis of Evidence

CAUTIs are among the most common hospital-acquired conditions and cost about $340 million to $450 million annually in the United States.27,28 Seventy-five percent of hospital-acquired UTIs are from urinary catheters,29 resulting in increasing patient discomfort, length of stay, cost, and mortality.30 Interventions include using catheters only when indicated and early removal; using alternatives to indwelling urethral catheters; and appropriate catheter care, maintenance, and removal.29

Practice Change

The timing of metal care changed from once to twice daily for patients with an indwelling catheter and discontinuing routine urinalysis for asymptomatic patients.31 NAs performed 4 of the 6 CAUTI prevention bundle elements—keep it clean, keep it secure, keep it closed, and keep it low (Table 3).

Table 3
Table 3:
Evidence-Based CAUTI Bundle Elements

A baseline knowledge assessment guided education. The EBP CC focused on 1:1 “back to the basics” training that addressed cares within the NA scope of practice. Education covered terminology, key evidence, meatal care procedure, and documentation. The EBP CC established rapport with each NA and was a role model and resource.

Implementation

The EBP Implementation Model19 presented in the EBP CC training guided phased implementation strategy selection (Figure 1). Discussions at unit staff meetings created awareness and interest (phase 1). Information was reinfused in unit newsletters. Knowledge and commitment (phase 2) were built via 1:1 NA education. Highly engaged NAs elected to serve as core group members, sharing information with their peers. A quick reference guide, “Keep It Simple,” for basic catheter care was reviewed. Skill competence prepared each NA, and materials were displayed on a unit bulletin board. After NAs performed correct meatal cares through return demonstration during competency training, action and adoption (phase 3) occurred as part of the “go live.” Pursuing integration and sustained use (phase 4) included peer influence accompanied by strategic internal reporting with actionable and timely feedback. Reinfusion occurred when a CAUTI was experienced. Figure 1 identifies the full list of strategies used.

Figure 1
Figure 1:
Implementation strategies used for CAUTI project and by EBP CCs.

Evaluation

Evaluation included NA knowledge and patient outcomes. Seventeen NAs completed training and a 7-item pretest and posttest. Mean cumulative test scores improved (pre = 3.31, post = 6.4). CAUTI rates improved 6 months preprogram to postprogram (pre = 0.78/1000 catheter-days, post = 0.00/1000 catheter-days). In fact, only 2 CAUTIs occurred in over 32 months after the program, and the unit continues to outperform benchmarks. The Agency for Healthcare Research and Quality (2017)32 estimates each CAUTI costs $13 793 per event. A more conservative estimate for this EBP CC impact on their unit is a cost savings of $54 312 to $109 368 using more recent estimates.28

Program Evaluation and Outcomes

Educational program evaluation occurred immediately following training and during a postprogram follow-up meeting. Thirty-eight of the 40 invited EBP CCs and NLPs attended the formal training; 86% (n = 18/21) of EBP CCs and 63% (n = 12/19) of NLPs completed the evaluation.

Participants were highly motivated. One EBP CC stated, “I would like to be a difference maker in my practice area.” Another stated, “I'm excited to help improve patient outcomes and make a positive impact.” Respondents (n = 30, 100%) identified their objectives as being met. Ninety-six percent indicated the program prepared them to act as an EBP CC, stating that the program “assist[ed] point-of-care nurses to function as a change agent applying evidence-based care in daily practice to improve patient care and outcomes.”

Participants indicated program materials were useful (mean, 3.5; 1- to 4-point Likert scale, 1 = strongly disagree to 4 = strongly agree). More than 80% reported prerequisite materials were helped prepare them, with specific prerequisites rating their agreement (online module 3.2; readings 3.1). Participants indicated the program prepared them to be an EBP CC (3.4); helped them understand implementation (3.4); that they had sufficient topic information (3.6); and it stimulated innovative thinking (3.6). In open-ended items, participants identified liking the shared learning, knowing how to implement, and how to develop a plan for the practice change. Identified needs included time for team meetings, data collection, a timeline, and follow-up on topics and implementation. Idea sharing was valued for “promot[ing] collegiality between units.” An additional suggestion was to differentiate roles more distinctly.

Following training, EBP CC-NLP pairs participated in a postprogram follow-up session at 1 or 2 months based on schedule availability. Eighty-four percent (n = 32/38) participated. Group discussion was used to obtain feedback. Teams provided progress reports, shared implementation strategies used, and participated in brainstorming to troubleshoot common problems. Participants reported activities including coordinating with NMs for planning; identifying and recruiting early adopters, reviewing evidence, and observing clinicians to gain understanding of current practice to guide implementation planning. They reported implementation strategies used, most of which came from “Promote Action & Adoption” (phase 3) & least from “Pursue Integration & Sustained Use” (phase 4) (Figure 1). Teams identified the EBP CC program “was very helpful in understanding how we implement change.”

Discussion

This EBP CC program was a pilot with an expectation of making revisions. Operationalizing the EBP CC role requires fidelity to achieve positive outcomes. The exemplar EBP CC-NLP was highly effective in promoting their roles, implementing EBP, and reducing CAUTI. The NM had EBP expertise the team could build upon, was effective in securing release time for project work, and optimized the EBP CC role. The point-of-care nurse in the EBP CC role was positive, credible, and highly effective in assessing NAs' learning needs, sharing easy to understand evidence, using informal troubleshooting, and providing actionable feedback.

Lessons learned are being applied in subsequent programs. Priority topics were narrowed for focused effort and greater impact across the organization. Participants from each clinical division work on the same topic to create synergy among clinical areas and natural links to unit-based councils and divisional quality committees. Participants are, or will be, invited to become members of shared governance committees. Program content emphasizes differentiated roles and how to best collaborate. Regularly scheduled follow-up is expected in unit-based councils, divisional quality meetings, divisional administrative meetings, departmental quality meetings, and topic-specific committees. Committees support regular reporting of EBP CC activities, troubleshooting, and recognition for incremental successes to build EBP CC expertise and increase their ability to lead within interprofessional teams.

Implications

All nurses have an opportunity to lead change. The EBP CC has a distinct role which must be operationalized to make an impact. This program provided an opportunity for point-of-care nurses to learn how to increase their peer influence, promote EBP, and improve outcomes. Adding this program into a comprehensive set of EBP training offerings provides additional opportunity for nurses to learn across their career. This program addressed top-down priorities and complements other programs that provide bottom-up innovations.

Conclusions

The EBP CC program involved selection of priority institutional quality indicators and emerging point-of-care nurse leaders by nurse leaders. The program applied the Iowa Model, EBP implementation strategies, change agent roles, and best evidence. The goal was to jump-start focused work at the EBP design and pilot step. A case exemplar demonstrated an impact from EBP CC-NLP actions and strong NM support for follow-through on CAUTI. Linking EBP CCs within the shared governance committees can optimize support from experts and those committees.

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