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Anatomy of an evidence-based policy

Blankenship, Susan MS, BSN, RN, PCCN; Lucas, Amy BSN, RN, CCRN;; Sayre, Sandy MSN, RN, APRN, CVN

doi: 10.1097/01.NURSE.0000429799.26483.64
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Susan Blankenship is the Clinical Educator for vascular services at Carilion Clinic Roanoke Memorial Hospital, Roanoke, Va. At the same facility, Amy Lucas is a staff nurse and preceptor in the vascular ICU and Sandy Sayre is unit director, vascular ICU.

The authors have disclosed that they have no financial relationships related to this article.

Nursing is a progressive art in which to stand still is to have gone back”.

—Florence Nightingale1

A HOSPITAL'S POLICIES AND PROCEDURES provide a plan of action to address a risk or concern. Because they guide daily practice, they must constantly evolve to remain current and based on the best evidence available.2,3 When policies are outdated or inadequate to guide an important aspect of patient care, nurses should step up to fill the void. No nurse should hesitate to voice questions and initiate changes to current practice in order to create a better, safer environment for patients.

This article describes the evolution of a new evidence-based policy initiated by ICU nurses who recognized the need for one. Nurses in any setting can use this structured approach to create and implement a new policy in their hospitals.

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Recognizing a need

Our journey in policy development began in the vascular ICU (VICU), when we received a patient from the OR with a lumbar drainage device (LDD), a sterile closed system used to continuously drain cerebrospinal fluid from the subarachnoid space.4 Unfamiliar with the nursing care for a patient with a LDD, the patient's nurse looked for a policy—and discovered that our unit had no specific policy to guide the care of this patient. The only policy available addressed the care of patients recovering from thoracic aneurysm repair in the cardiac surgery ICU. She consulted with nurses from that unit and used their policy and procedure to make this a safer situation for the patient. The confusion caused by this lack of guidance didn't endanger the patient, but it did cause frustration for the ICU nurse.

To prevent this confusion from happening again, we were encouraged by administration to create a policy for managing the LDD in neurosurgical patients. In response to this request we formed a group and, with some trial and error, created an evidence-based policy for the care of a neurosurgical patient with an LDD.

Many authorities, such as Collins and Patel, Jeffries et al., and Cullen and Adams, advocate a structured approach to evidence-based practice, whether for policy writing or practice changes.2,5,6 We created a seven-step process entitled Policy Development Seven (PD7) to construct the new policy.

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Step One: Identifying the need

We identified a need when we encountered an unfamiliar patient-care situation. A need may also be discovered when someone asks a question that can't be answered by current policy. New technology, regulatory changes, and sentinel events may also indicate a need for policy changes. Once you've identified a need, you should discuss it with someone in the organization who can determine if the organization should pursue policy development for the issue.6

Our hospital has a committee that reviews and approves policies. To make our case to the committee, we presented a project proposal that outlined expectations, deadlines, resources, and checks and balances for completion of the project. Here are some of the key questions we answered to organize and present our project proposal.

  • Project detail: What issue is being addressed and why it is important? We needed a policy to guide care of neurosurgical patients with LDDs to ensure proper care and reduce risks.
  • How much time will be involved? We needed time to do literature reviews and write the policy, which we estimated would be several hours of work in addition to time to attend policy committee approval meetings. Being new to policy writing, we underestimated the amount of time we'd need. Each primary team member contributed 2 or 3 hours per week.

We had both salaried and hourly employees in our group, so we also had to consider scheduling to prevent overtime. We planned to schedule meetings at least weekly, but needed to be careful not to assign the hourly employee so much for the next meeting that the individual would go over the allotted hours per week.

  • What's the timeframe for completion? Our project didn't require a definite deadline, but we wanted to complete it as soon as possible because we had no policy guidance for these patients and several of them had been admitted to our unit recently.
  • How will it benefit the department and organization? This policy would set an evidence-based standard of care for neurosurgical patients with LDDs in our hospital, eliminating variances in their care.
  • What do you expect from the people approving your project proposal? In this case, a manager was on the team creating the policy, so she was expected to assist with meeting deadlines and writing. She also had to approve the hours for the hourly employee. If you don't have a manager on your team, you may just expect support in the way of allowing enough hours to complete the project.
  • What hospital resources will you need? We used meeting rooms in the hospital and received help from the hospital system librarian and the hospital's online databases to do research. We also asked for help from neurosurgery and the preceptor of the neuro-trauma ICU, who was also an hourly employee.
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Step Two: Create the policy writing team

Who should write the policy? We recommend a team approach; the benefits are confirmed in the literature.6 This approach lets you break up the tasks among several people and obtain different perspectives as you write.

You should ask several questions when deciding who should be on the team for writing the policy. For example:

  • Who will this policy impact? Choose nurses with expertise in the practice area that will follow the new policy.
  • Who can commit the time needed to create the policy? If this is a direct care nurse, will the manager approve hours away from bedside care for research and writing?
  • How much will the policy change practice? If it will affect a large area or involve a change in equipment, having someone from leadership on the team expedites navigation through hospital committees.
  • Should you add ad hoc members and key stakeholders as needed to offer helpful insight, advice, or direction?

Of all these considerations, we found the most important were the ability to meet the time commitment and the motivation to meet team goals.

Our team consisted of the manager of the VICU, the preceptor of the same unit, and the clinical educator of the vascular area. While a team member from a vascular area may not seem like the first choice for creating this policy, the VICU staff was directly affected by the lack of a policy. Collins and Patel recommend involving key stakeholders early in the process to ensure the policy fits with current organizational mission and goals.2

We also added a few ad hoc members—a neurosurgeon and the preceptor of the neuro-trauma ICU—who agreed to read policy drafts and offer suggestions based on their experience and expectations of nurses caring for these patients. At times we included the product representative for the company that supplies our LDD and managers of other departments that would be affected by our policy. Although experience with the subject matter is helpful, it's not absolutely necessary for all team members because the team will be reviewing the most current literature and networking with those who do have experience.

Team members should be clear on their roles and preferred methods of communication, and someone should be designated the leader. This could be the person who originally discovered the problem or a manager. It's helpful if this person has leadership experience. Along the same lines, when making plans and assignments for the next meeting, be sure everyone is clear about what his or her job is. Consider individual strengths and capitalize on these strengths as you prioritize assignments.

We had a small group working on this project, but we still found it helpful to send out minutes and assignments by e-mail at the end of each meeting to clarify everyone's assignment for the next meeting. Once we began communicating with others about this policy, these written communications became essential.

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Step Three: Gather information and review the literature

The librarian for your health system library is a great resource for gathering and evaluating the evidence.6,7 Nurses also frequently use databases such as the Cumulative Index of Nursing and Allied Health Literature, Medline, the Education Resources Information Center, and PsychINFO.

A big challenge in this process is choosing keywords that are broad enough but not too broad.7 We used our librarian and EBSCO, a database available through our hospital's health sciences library that combines several of the above-mentioned databases into one search. We discovered other sources in our search as well. We asked the clinical nurse specialists in the related areas and the representative for the company that supplies our LDD and ventriculostomy equipment for any information they might have. We also searched the state nurse practice act for limitations, obtained policies from other hospitals, and polled our own hospital's preceptor committee to see how they cared for patients with LDDs.

Once you've collected information, you must evaluate it before using in a policy. You may find anything from results of a randomized clinical trial to expert opinion and must determine what information is the most recent and reliable. Multiple randomized clinical trials will give you the best evidence.7 Clinical practice guidelines are also good sources. If you can't find these you may have to rely on expert opinion, but this is considered a lower level of evidence and shouldn't be the first choice in writing a policy or making a practice change.3,6

After we'd conducted a literature review and compared our results, we were disappointed to discover how little evidence was available to guide practice in caring for patients with LDDs. All of the most current articles referenced an American Association of Neuroscience Nurses (AANN) article published in 2007.4 The information provided by the product representative turned out to be this same article. You may find similar drawbacks when you search for information on best practices. If so, make sure that you have the most current information available from a peer-reviewed source or a leading professional authority, such as the Association of Critical Care Nurses or AANN.

In researching our hospital's current practice of caring for patients with LDDs, we discovered that the preceptor group had the same questions and concerns that we did, but no consensus regarding practice. We also discovered that no adverse events had been reported related to the use of LDDs in our facility. We found that the same drainage system was being used for LDDs and ventriculostomies; however, this system was stocked in only a few areas and wasn't readily available from our materials management department. This explained some of the procedural and equipment challenges we encountered with the patient who inspired our original question.

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Step Four: Organize and write policy

Although some literature recommends writing policies as a way to integrate an evidence-based change in practice,6 literature describing the process is scarce. We used the existing LDD policy used in the cardiac surgery ICU as a guide to structure ours.

The writing of our new policy was simplified by the fact that we had only one reference to use, the AANN guidelines.4 Another policy might have required us to compile evidence into our outline or even investigate conflicting information to find the best practices. We took care to write without using brand names when referring to the equipment in case the hospital was to change suppliers.

Our team benefited from reserving a conference room with a projector so we could project the work on a screen. As the team brainstormed ideas, one team member typed them and everyone could see the work immediately. Typing our work onto the screen also produced an immediate electronic copy of the draft that was e-mailed to everyone in the group after each meeting. We used the draft to complete our personal assignments and to send to others for expert advice.

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Step Five: Revision

Once we had a rough draft, it was time to revise. Besides the obvious spell and grammar check, this involved asking our experts to read and critique it. We sent copies to the preceptor of the neuro-trauma ICU and the chief neurosurgery resident and arranged a meeting with them to discuss our policy and questions that we still had. These two brought the experience and perspective we needed to create a policy that would meet everyone's needs and could be realistically followed. The resident was also in contact with his attending so that their entire group would be aware of and approve of the policy. This meeting clarified questions we had after looking at the AANN reference and also clarified the level of care for these patients. The physicians agreed to keep the patients on at least a progressive care unit because of the frequent assessment they required. However, because this patient population was so small, we also pursued limiting the units where these patients could be admitted to ensure the nurses stayed competent in their care. Our manager was able to meet with the appropriate people and get this approved so we could list the designated units in the policy.

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Step Six: Submit for approval

We submitted the final policy with references to the Adult Practice Council (APC) for approval. The APC is a committee of nurses from throughout the hospital in charge of overseeing policy creation and revision. The council's recommendations should be received as constructive feedback that will lead to an improved policy.

Each member of the APC received a copy of our policy before meeting. Some of our team members were present at the meeting to describe the basic parts of the policy and who'd be affected. We also spoke about the designated units. We made sure the APC had the names of everyone who'd need to sign off on this policy. Personnel in our bed placement center were especially important because they'd be the ones assigning patients' beds based on physician orders.

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Step Seven: Education and dissemination

The final step in this process is to educate the staff. This can be done through hospital leadership meetings, self-learning packets, e-mail, or unit-to-unit education. Most hospitals have a process for disseminating information of this nature. Computers have made this easier via the in-house intranet, which lets staff review the most updated version of any policy online.2 All of our hospital policies are found on our intranet.

In our hospital, we submitted an education request form through the intranet to human resources so that our policy would be included in monthly education and leadership meetings. Most of our policy education centers on raising awareness of the policy so staff will know where to find it when they need it. This education should take place before the policy is active and the equipment available. The areas directly responsible for caring for these patients received hands-on information and practice both on the unit and during a mandatory annual skills day.

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Order sets and other issues

When you write or revise a policy, you should consider creating an order set to complement it. When we did our fact finding about LDDs, we discovered some issues that couldn't be resolved with a simple policy. LDDs are inserted for various reasons, and patient care differs slightly based on that reason. Orders by healthcare providers didn't always accurately describe the care needed for each individual patient. Although the policy stated what specific orders were needed, we felt we needed something more.

As a complement to the policy, we began work on a physician order set for patients with LDDs. The neurosurgeons agreed to the order set and it was approved by the appropriate people.

Writing and revising policies is also a good time to evaluate the equipment that goes with it. The representative of the company that supplies our hospital's drainage system provided us with information about our current drainage system and some other types. Some of the other systems worked the same way but seemed safer, sturdier, and easier to use. Taking into account cost, ease of use, and safety, the product committee approved changing to a different drainage system. The product representative was very supportive of our entire process by providing information and educating the units that would be affected by this change.

One of the biggest obstacles in undertaking this project was time. You should plan for changes to your timeline and meeting schedules in case of unexpected or anticipated events that interrupt the workflow. In our case, a member of our group had to take a leave for surgery during policy revision. We also had an update to our electronic medical record system while we were writing that took time away for education and delayed order set development. Our neurosurgery resident had limited time to meet with us as he was studying for and taking his final tests.

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Pioneers on the frontiers of change

As healthcare reform continues to transform our hospital systems, healthcare professionals must also evolve by relying not on traditional practice, but on best practices based on evidence. Nurses must be pioneers on the frontier of change.

Inspired by this mandate, our group accepted the challenge of writing a LDD policy. Despite our limited experience, we succeeded by following a step-by-step approach, beginning with researching the issue and ending with implementing a completed policy. (See Lessons learned.) By sharing our experience, we hope to empower and engage others who share our passion for creating a more perfect environment for our patients.

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Lessons learned

Based on our experience, these tips can help facilitate the policy-making process.

  • Engage a multidisciplinary team.
  • Involve key players early in the process.
  • Find out how people like to communicate and receive information; for example, by phone, e-mail, or in person.
  • Consider how members work together, taking into account differing personalities and viewpoints. A personality trait tool can help you evaluate leadership styles and team members' personality type to assist with creating a well-rounded team.
  • Consider who can best meet your needs in terms of competency, education level, risk management, bedside nurse usage, quality management, budget, and computer skills.
  • Consider all patient populations that may be affected by the policy.
  • Know when and where you'll be holding the next meeting before you leave each session, and be sure all team members are clear about their assignments for the next meeting.
  • Expect each member to pull his or her weight by completing assignments and coming prepared to meetings. Establish guidelines up front regarding participation and what will happen if someone can't meet these requirements (you may need to consider ad hoc members).
  • Keep notes of each meeting to keep track of minutes, dates and times, and time spent.
  • Know your hospital resources ahead of time to avoid delays.
  • Acknowledge key contributors' assistance with thank-you notes and letters to their manager.
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