Planning for Implementation of Evidence-Based Practice

Implementing an Evidence-Based Functional Pain Assessment Scale in an Adult Inpatient Unit

BACKGROUND

The focus on pain assessment using a single, one-dimension pain assessment scale can be problematic. Locally, challenges we faced with this were; a) pain was percieved as not being effectively managed, b) patients with chronic pain were not having their pain adequately controlled, and c) misconceptions and subsequent confusion between health care teams and patients related to what pain intensity scores mean to each individual.

AIMS

The purpose of this paper is to describe an evidence-based practice project aiming at improving pain assessment through the implementation of a Functional Pain Scale (FPS) on an adult inpatient cardiothoracic unit.

DESIGN

The Iowa Model-Revised and the Implementation Strategies for Evidence- Based Practice Guide served as the framework for this project.

SETTING

Over an 18-month period at a academic tertiary medical center in the midwest.

PARTICIPANTS/SUBJECTS

Staff and patients on an adult inpatient 48-bed medical and surgical cardiothoracic unit.

METHODS

Following a synthesis of the evidence, implementation of the FPS required various strategies, such as, individualized patient and staff education, audit and feedback, a pain policy revision, and creating documentation in the electronic medical record. Evaluation of the FPS consisted of patient and staff surveys pre- and postimplementation to assess knowledge, attitudes, and behaviors.

RESULTS

After the pilot period, over 75% of the patients preferred to use the FPS and almost all the patients found the scale easy to use. Nurses reported an increase in perception that pain documentation was complete, that the FPS allowed them to accurately document their patients' pain experience, and that their patients were well informed of their pain management plan.

CONCLUSIONS

This project supports successful implementation of the FPS within nursing workflow. The goal of using the FPS is to change pain management discussions from an intensity reduction to meeting goals of care, aligning expectations, and creating common language among patients and providers.

Improving Pediatric Hypertension Screening in an Academic Primary Care Setting

Introduction

Adherence to the American Academy of Pediatrics clinical practice guidelines for screening and managing high blood pressure (BP) is low. This team sought to improve recognition and documentation of relevant diagnoses in patients aged 13-20 years who presented to general pediatric clinics.

Methods

The primary outcome measure was the proportion of office visits for patients ages 13-20 with a BP ≥ 120/80 with a visit or problem list diagnosis of hypertension or elevated BP. Secondary measures included (1) the proportion of patients who had their BP measured in the right arm, (2) the proportion of patients who had a mid-arm circumference measurement recorded, and (3) the proportion of patients who had a second BP reading measured at the visit. Interventions addressed key drivers for evidence-based high BP screening: standard BP measurement, electronic health record clinical decision support, and clinical pathway adoption. Data were collected over a twenty-seven-month period and plotted using the Laney p' chart.

Results

Provider documentation of elevated BP or hypertension improved from a baseline mean of 24% in April 2020 through January 2022 to 41% in February 2021 through June 2022. All secondary outcome measures also demonstrated significant improvement.

Conclusions

This project demonstrates the feasibility of improving adherence to best practices of BP measurement in primary care clinics through education, acquisition of resources, and implementation of electronic health record flags for abnormal values.

Health-care organization characteristics in cancer care delivery: an integrated conceptual framework with content validation

Context can influence cancer-related outcomes. For example, health-care organization characteristics, including ownership, leadership, and culture, can affect care access, communication, and patient outcomes. Health-care organization characteristics and other contextual factors can also influence whether and how clinical discoveries reduce cancer incidence, morbidity, and mortality. Importantly, policy, market, and technology changes are transforming health-care organization design, culture, and operations across the cancer continuum. Consequently, research is essential to examine when, for whom, and how organizational characteristics influence person-level, organization-level, and population-level cancer outcomes. Understanding organizational characteristics-the structures, processes, and other features of entities involved in health care delivery-and their dynamics is an important yet understudied area of care delivery research across the cancer continuum. Research incorporating organizational characteristics is critical to address health inequities, test care delivery models, adapt interventions, and strengthen implementation. The field lacks conceptual grounding, however, to help researchers identify germane organizational characteristics. We propose a framework identifying organizational characteristics relevant for cancer care delivery research based on conceptual work in health services, organizational behavior, and management science and refined using a systematic review and key informant input. The proposed framework is a tool for organizing existing research and enhancing future cancer care delivery research. Following a 2012 Journal of the National Cancer Institute monograph, this work complements National Cancer Institute efforts to stimulate research addressing the relationship between cancer outcomes and contextual factors at the patient, provider, team, delivery organization, community, and health policy levels.

Evidence-Based Pain Assessment in Nonverbal Palliative Care Patients

BACKGROUND

Central to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering.

AIMS

The purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients.

DESIGN

The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks.

SETTINGS

On a six-bed adult inpatient Palliative Care Unit (PCU).

PARTICIPANTS/SUBJECTS

Nonverbal palliative care patients.

METHODS

Evidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption.

RESULTS

Nurses' attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores.

CONCLUSIONS

MOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

'Capacity building skills in the implementation of evidence-based practice for community health nurses: an exploratory descriptive cohort study'

Background: While nurses are strategically placed to support the achievement of universal health, their practice may not always be informed by evidence, especially in a context where research evidence is not commonly used to inform practice.Objective/Aim/Hypothesis: Improve management of clients with CNCDs in Caribbean community through evidence-based practice (EBP) capacity building workshops.Design/Methods: A descriptive, quantitative design was used for this study. Participants included Community Based Nurses who attended an initial and recall workshop on EBP in a Caribbean island. All participants were included as the sample. Data were collected as a Pre-Test and Post Test before the initial workshop and at the recall workshop. Analysis was done quantitatively. Since the sample was small, only descriptive statistics were used.Results: Data showed 64% of participants had no experience with EBP, 55% needed more essential resources to participate in EBP and 55% recognized a need to include EBP to change their clinical practice effectively.Conclusions: The nurses and district supervisors observed a high level of interest and commitment to initiating and completing EBP projects. However, the reality of significant workplace demands, and limitations in consistent logistical and supervisory support impacted long-term sustainability.

Beyond Plan-Do-Study-Act cycle - staff perceptions on facilitators and barriers to the implementation of telepresence robots in long-term care

BACKGROUND

Quality improvement (QI) programs with technology implementations have been introduced to long-term care (LTC) to improve residents' quality of life. Plan-Do-Study-Act (PDSA) cycle is commonly adopted in QI projects. There should be an appropriate investment of resources to enhance learning from iterative PDSA cycles. Recently, scholars explored possibilities of implementation science (IS) with QI methods to increase QI projects' generalisability and make them more widely applicable in other healthcare contexts. To date, scant examples demonstrate the complementary use of the two methods in QI projects involving technology implementation. This qualitative study explores staff and leadership teams' perspectives on facilitators and barriers of a QI project to implement telepresence robots in LTC guided by the Consolidated Framework for Implementation Research (CFIR).

METHODS

We employed purposive and snowballing methods to recruit 22 participants from two LTC in British Columbia, Canada: operational and unit leaders and interdisciplinary staff, including nursing staff, care aides, and allied health practitioners. CFIR was used to guide data collection and analysis. Semi-structured interviews and focus groups were conducted through in-person and virtual meetings. Thematic analysis was employed to generate insights into participants' perspectives.

RESULTS

Our analysis identified three themes: (a) The essential needs for family-resident connections, (b) Meaningful engagement builds partnership, and (c) Training and timely support gives confidence. Based on the findings and CFIR guidance, we demonstrate how to plan strategies in upcoming PDSA cycles and offer an easy-to-use tool 'START' to encourage the practical application of evidence-based strategies in technology implementation: Share benefits and failures; Tailor planning with staff partners; Acknowledge staff concerns; Recruit opinion leaders early; and Target residents' needs.

CONCLUSIONS

Our study offers pragmatic insights into the complementary application of CFIR with PDSA methods in QI projects on implementing technologies in LTC. Healthcare leaders should consider evidence-based strategies in implementing innovations beyond PDSA cycles.

Introducing a Digital Occupational Violence Risk Assessment Tool Into an Emergency Department: A Pilot Implementation Study

INTRODUCTION

Occupational violence in emergency departments is prevalent and detrimental to staff and health services. There is an urgent call for solutions; accordingly, this study describes the implementation and early impacts of the digital Queensland Occupational Violence Patient Risk Assessment Tool (kwov-pro).

METHODS

Since December 7, 2021, emergency nurses have been using the Queensland Occupational Violence Patient Risk Assessment Tool to assess 3 occupational violence risk factors in patients: aggression history, behaviors, and clinical presentation. Violence risk then is categorized as low (0 risk factors), moderate (1 risk factor), or high (2-3 risk factors). An important feature of this digital innovation is the alert and flagging system for high-risk patients. Underpinned by the Implementation Strategies for Evidence-Based Practice Guide, from November 2021 to March 2022 we progressively mobilized a range of strategies, including e-learning, implementation drivers, and regular communications. Early impacts measured were the percentage of nurses who completed their e-learning, the proportion of patients assessed using the Queensland Occupational Violence Patient Risk Assessment Tool, and the number of reported violent incidents in the emergency department.

RESULTS

Overall, 149 of 195 (76%) of emergency nurses completed their e-learning. Further, adherence to Queensland Occupational Violence Patient Risk Assessment Tool was good, with 65% of patients assessed for risk of violence at least once. Since implementing the Queensland Occupational Violence Patient Risk Assessment Tool, there has been a progressive decrease in violent incidents reported in the emergency department.

DISCUSSION

Using a combination of strategies, the Queensland Occupational Violence Patient Risk Assessment Tool was successfully implemented in the emergency department with the indication that it could reduce the number of incidents of occupational violence. The work herein provides a foundation for future translation and robust evaluation of the Queensland Occupational Violence Patient Risk Assessment Tool in emergency departments.

Development and Evaluation of the Fuld Institute Evidence-based Implementation and Sustainability Toolkit for Health Care Settings

Routine implementation and sustainability of evidence-based practices (EBPs) into health care is often the most difficult stage in the change process. Despite major advances in implementation science and quality improvement, a persistent 13- to 15-year research-to-practice gap remains. Nurse leaders may benefit from tools to support implementation that are based on scientific evidence and can be readily integrated into complex health care settings. This article describes development and evaluation of an evidence-based implementation and sustainability toolkit used by health care clinicians seeking to implement EBPs. For this project, implementation science and EBP experts created initial iterations of the toolkit based on Rogers' change theory, the Advancing Research through Close Collaboration (ARCC) model, and phases and strategies from implementation science. Face validity and end-user feedback were obtained after piloting the tool with health care clinicians participating in immersive EBP sessions. The toolkit was then modified, with subsequent content validity and usability evaluations conducted among implementation science experts and health care clinicians. This article presents the newly updated Fuld Institute Evidence-based Implementation and Sustainability Toolkit for health care settings. Nurse leaders seeking to implement EBPs may benefit from an evidence-based toolkit to provide a science-informed approach to implementation and sustainability of practice changes.

CE: An Evidence-Based Yoga Practice for Hospitalized Adults on Medical-Psychiatric Units

BACKGROUND

Yoga-based treatments, which are recognized by the National Institutes of Health's National Center for Complementary and Integrative Health as a form of complementary and alternative medicine, have proven to be beneficial for people with various psychiatric disorders, including depression, anxiety, posttraumatic stress disorder, and attention deficit-hyperactivity disorder, as well as schizophrenia and other psychotic disorders.

PURPOSE

The purpose of this evidence-based practice (EBP) project was to offer structured yoga sessions as a means of providing stress relief, promoting relaxation, reducing anxiety, and improving quality of care among male and female adult patients (ages 18 years and older) hospitalized in a locked medical-psychiatric unit within an academic medical center for treatment of both acute medical and acute psychiatric conditions.

PRACTICE CHANGE AND IMPLEMENTATION

The Iowa Model and Implementation Strategies for EBP provided the guiding framework for this pilot project. Patients were offered once weekly, 30-to-60-minute yoga sessions for 12 weeks and were screened for their ability to participate by the nurse-yoga instructor and the interprofessional team. Using a Precision Implementation Approach, a data-driven selection of strategies from the implementation framework promoted the adoption and sustainability of the practice change, which were further advanced through interprofessional reinforcement of yoga practice and internal reporting.

RESULTS

Patient feedback was sought before and after yoga sessions. Thirty-nine patients responded to the pre-yoga questionnaire and 38 patients responded to the post-yoga questionnaire. Patients reported improved mood after yoga, with 23% (nine of 39) reporting feelings of calm and relaxation pre-yoga compared with 76% (29 of 38) post-yoga, and 41% (16 of 39) reporting feelings of anxiety pre-yoga compared with just 5% (two of 38) post-yoga.

CONCLUSION

Yoga sessions provided by a nurse certified in yoga instruction improved patients' mood and sense of well-being. Instructional materials and videos were created to promote sustained use. The EBP of providing yoga sessions grew from a pilot program to a sustained change with more widespread use. In addition to patients hospitalized on medical-psychiatric units, the health system expanded the sessions to include inpatients on behavioral health units.

Evidence-informed practice: simplifying and applying the concept for nursing students and academics

Nurses' ability to apply evidence effectively in practice is a critical factor in delivering high-quality patient care. Evidence-based practice (EBP) is recognised as the gold standard for the delivery of safe and effective person-centred care. However, decades following its inception, nurses continue to encounter difficulties in implementing EBP and, although models for its implementation offer stepwise approaches, factors, such as the context of care and its mechanistic nature, act as barriers to effective and consistent implementation. It is, therefore, imperative to find a solution to the way evidence is applied in practice. Evidence-informed practice (EIP) has been mooted as an alternative to EBP, prompting debate as to which approach better enables the transfer of evidence into practice. Although there are several EBP models and educational interventions, research on the concept of EIP is limited. This article seeks to clarify the concept of EIP and provide an integrated systems-based model of EIP for the application of evidence in clinical nursing practice, by presenting the systems and processes of the EIP model. Two scenarios are used to demonstrate the factors and elements of the EIP model and define how it facilitates the application of evidence to practice. The EIP model provides a framework to deliver clinically effective care, and the ability to justify the processes used and the service provided by referring to reliable evidence.

Iowa Implementation for Sustainability Framework

Background

An application-oriented implementation framework designed for clinicians and based on the Diffusion of Innovations theory included 81 implementation strategies with suggested timing for use within four implementation phases. The purpose of this research was to evaluate and strengthen the framework for clinician use and propose its usefulness in implementation research.

Methods

A multi-step, iterative approach guided framework revisions. Individuals requesting the use of the framework over the previous 7 years were sent an electronic questionnaire. Evaluation captured framework usability, generalizability, accuracy, and implementation phases for each strategy. Next, nurse leaders who use the framework pile sorted strategies for cultural domain analysis. Last, a panel of five EBP/implementation experts used these data and built consensus to strengthen the framework.

Results

Participants (n = 127/1578; 8% response) were predominately nurses (94%), highly educated (94% Master’s or higher), and from across healthcare (52% hospital/system, 31% academia, and 7% community) in the USA (84%). Most (96%) reported at least some experience using the framework and 88% would use the framework again. A 4-point scale (1 = not/disagree to 4 = very/agree) was used. The framework was deemed useful (92%, rating 3–4), easy to use (72%), intuitive (67%), generalizable (100%), flexible and adaptive (100%), with accurate phases (96%), and accurate targets (100%). Participants (n = 51) identified implementation strategy timing within four phases (Cochran’s Q); 54 of 81 strategies (66.7%, p < 0.05) were significantly linked to a specific phase; of these, 30 (55.6%) matched the original framework. Next, nurse leaders (n = 23) completed a pile sorting activity. Anthropac software was used to analyze the data and visualize it as a domain map and hierarchical clusters with 10 domains. Lastly, experts used these data and implementation science to refine and specify each of the 75 strategies, identifying phase, domain, actors, and function. Strategy usability, timing, and groupings were used to refine the framework.

Conclusion

The Iowa Implementation for Sustainability Framework offers a typology to guide implementation for evidence-based healthcare. This study specifies 75 implementation strategies within four phases and 10 domains and begins to validate the framework. Standard use of strategy names is foundational to compare and understand when implementation strategies are effective, in what dose, for which topics, by whom, and in what context.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01157-5.

Compliance With Best Practice Guidelines for Neurodevelopmental Supportive Care in South Africa: A Situational Analysis

Neurodevelopmental supportive care provides preterm infants with evidence-based care to ensure the best possible neurological outcomes. The study aimed to determine the compliance of current nursing care practices with best practice guidelines by means of a situational analysis. The situational analysis was done in 2 cycles in the neonatal intensive care units (n = 25) of a private healthcare provider in South Africa. Structured observations were done in cycle 1 using the Implementation of Neurodevelopmental Supportive Care checklist. Cycle 2 comprised focus group discussions to verify findings from cycle 1. Seventeen conclusion statements were formulated, which were thematically combined to be presented as 9 categories: neonatal intensive care unit design, individualized care, family-centered care, infant positioning, handling techniques, environmental manipulation, pain management, knowledge of infant behavior, and feeding. The conclusion statements identified improvement opportunities in current practice and offer suggestions, which can be used to guide an implementation strategy for best practice guidelines of neurodevelopmental supportive care in the neonatal intensive care units of the private healthcare group in future. Addressing improvement opportunities in all the categories will ensure that all aspects of the guideline requirements are met, resulting in a comprehensive strategy improving practice and patient outcomes.

Reducing contamination of midstream urine samples through standardized collection processes: a best practice implementation project

OBJECTIVE

The objective of this project is to decrease the rates of midstream urine sample contamination through standardization of evidence-based techniques among nurses.

INTRODUCTION

Urinary tract infection is a prevalent health problem worldwide. The diagnosis and treatment of urinary tract infection depend on a thorough physical examination and the results of an uncontaminated midstream specimen of urine. However, improper techniques used in the collection often cause sample contamination, leading to delayed diagnosis and the use of inappropriate antibiotics for treatment. As nurses are at the forefront of care delivery, they are involved in reducing the rates of midstream urine sample contamination. Thus, the use of an evidence-based approach to standardize collection of midstream urine culture is crucial for the provision of higher-quality patient care.

METHODS

Education sessions were delivered to the nurses and an evidence-informed standardized patient education leaflet was crafted by the project team for implementation. With a sample size of 30 nurses and patients, the project took place in a 21-bed adult surgical ward in a hospital in Singapore. The JBI Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) programs were used to implement the evidence-based project. The project was implemented in three phases from October 2018 to January 2019. A standardized audit tool devised from JBI PACES was used for the audits in this project. The rates of midstream urine specimen contamination and the knowledge of nurses were also monitored.

RESULTS

The baseline audit revealed that the nursing staff required educational sessions to improve their knowledge of midstream urine sample collection. Aside from criteria 1,3 and 4, the remaining criteria achieved compliance of more than 80%. The criteria below 80% compliance became the main focus of the project interventions. At follow-up cycle 1, all criteria achieved at least 80% compliance except criteria 4 and 5, which achieved 73% and 69% compliance, respectively. At the three-month post implementation audit, all criteria achieved a compliance rate of at least 80%. Fisher's exact test was carried out, and statistical significance of the results was achieved (p < 0.001) when compared to baseline audit. The rates of midstream urine specimen contamination also significantly decreased from 40% at the baseline audit to 20% at the third-month post implementation audit. Nurses' knowledge markedly improved as measured by the three-question quiz.

CONCLUSION

This evidence-based implementation project highlights the effectiveness of the JBI PACES and GRiP processes for initiating best practice within a nursing environment. The use of JBI best-practice recommendations to standardize methods for midstream urine specimen collection effectively reduced the rates of midstream urine contamination.

Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality

BACKGROUND

Translating research into practice is complex for clinicians, yet essential for high quality patient care. The field of implementation science evolved to address this gap by developing theoretical approaches to guide adoption and sustained implementation of practice changes. Clinicians commonly lack knowledge, time, and resources of how evidence-based practice (EBP) models can guide implementation, contributing to the knowledge-to-practice gap.

AIM

This paper aimed to equip clinicians and other healthcare professionals with implementation science knowledge, confidence, and models to facilitate EBP change in their local setting and ultimately improve healthcare quality, safety, and population health outcomes.

METHODS

The field of implementation science is introduced, followed by application of three select models. Models are applied to a clinical scenario to emphasize contextual factors, process, implementation strategies, and outcome evaluation. Key attributes, strengths, opportunities, and utilities of each model are presented, along with general resources for selecting and using published criteria to best fit clinical needs. Partnerships between implementation scientists and clinicians are highlighted to facilitate the uptake of evidence into practice.

LINKING EVIDENCE TO ACTION

Knowledge of implementation science can help clinicians adopt high-quality evidence into their practices. Application-oriented approaches can guide clinicians through the EBP processes. Clinicians can partner with researchers in advancing implementation science to continue to accelerate the adoption of evidence and reduce the knowledge-to-action gap.

The realities of practice change: Nurses' perceptions

AIMS AND OBJECTIVES

To explore registered nurses' perceptions of practice change and describe factors that influence the adoption of practice changes.

BACKGROUND

Nurses play a critical role in optimising patient outcomes. Healthcare organisations and nurses must do their part to achieve the Quadruple Aim, which requires nurses to change their practice. Nurses are ideally positioned to improve patient outcomes by changing their practice to align it with research evidence and organisational initiatives; however, this experience of practice change by nurses is grossly under-studied.

DESIGN

A qualitative design, inductive content analysis, was used to understand nurses' perceptions of practice change.

METHODS

Eleven registered nurses, who worked in one hospital system, participated in one-on-one semi-structured interviews. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) were followed.

FINDINGS

The 11 participants described 63 distinct experiences with practice changes. Their experiences with and perceptions of practice change are categorised as (1) There is A History; (2) It's A Lot of Work; (3) It Happens to Nurses; and (4) Doing Right for the Patient.

CONCLUSION

Nurses experience practice change as a central part of the work they do; it occurs frequently and multiple practice changes may co-occur. Nurses identify strategies, such as thoughtful planning, engaging nurses, and communicating the rationale for and the outcomes of the practice change, to facilitate changing practice.

RELEVANCE TO CLINICAL PRACTICE

Involving nurses in practice changes could alleviate some inhibiting factors for adopting new practices. Local hospital and national policies should explore creative and practical ways to balance the competing needs of nurses providing direct care at the bedside and dedicated time to be engaged in practice change initiatives. With the ongoing focus on improving patient care and optimising patient safety, nurses should be viewed as highly valued members of the team when designing and implementing practice changes.

Pediatric Pain Assessment in the Intensive Care Unit: An Evidence-Based Algorithm

BACKGROUND

Conducting an adequate pain assessment in the Pediatric Intensive Care Unit (PICU) is multifactorial and complex due to the diversity of the population. It is critical that validated pain assessment methods are used appropriately and consistently to aid in evaluation of pain and pain management interventions.

PURPOSE

The aim of this evidence-based practice project was to improve pain assessment practices in the PICU through a decision-support algorithm.

DESIGN & METHODS

The Iowa Model-Revised was used to guide the development and implementation of an evidence-based decision algorithm. Pre- and postdata were collected via surveys (nursing knowledge and confidence) and documentation audits (nursing pain assessments). Various implementation strategies were used to facilitate the integration and sustainability of the algorithm in practice.

RESULTS

The majority of survey items showed an increase in nursing knowledge and confidence. Audits of pain assessment documentation displayed an increase in appropriate pain assessment documentation related to a child's communicative ability. However, there is a need for reinfusion related to the documentation of sedation assessments.

CONCLUSIONS

The use of an algorithm supported the ability of PICU nurses to critically consider and choose the pain assessment method most appropriate for the patient's condition. The algorithm promotes nursing clinical judgement, prioritizes pain management, and includes patients receiving sedation. The algorithm supports a comprehensive pain assessment in a difficult pediatric patient population. Future research is needed to strengthen and standardize the usage of terms "assume pain present" and "assume pain managed," and to also improve the overall feasibility and effectiveness of the algorithm.

Otago exercise programme-from evidence to practice: a qualitative study of physiotherapists' perceptions of the importance of organisational factors of leadership, context and culture for knowledge translation in Norway

Background

Falls and fall-related injuries are a major public health problem and an international priority for health services. Despite research showing that evidence-based fall prevention is effective, its translation into practice has been delayed and limited. Although organisational factors such as leadership, culture and context are key factors for implementing evidence-based practice, there is still limited information on whether these factors represent barriers in the Norwegian and international healthcare context. Thus, this study aimed to explore the views of physiotherapists in clinical practice and their leaders’ views on the importance of organisational factors, such as leadership, culture and contextual and human resources, regarding successful knowledge translation of the Otago evidence-based fall programme in a Norwegian community.

Methods

Four in-depth interviews with physiotherapists and a focus group interview with nine physiotherapists and leaders representing local hospitals and municipalities were conducted to collect data. The data were analysed using a thematic analysis.

Results

The analysis yielded an overarching theme: an empowering leader as an anchor is needed for successful knowledge translation of physiotherapists’ and leaders’ views about the role of organisational structure, leadership, culture, financial resources and competence in research-based knowledge, as well as how to enhance the clinical staff’s expertise. Four main themes further elaborated on the overarching theme: (1) multifactor leadership—the importance of reinforcement, knowledge, goals and attention; (2) potential for change in professional roles as shaped by culture, context and type of practice; (3) knowledge translation—the tension between real-life capabilities, optimism and learning; and (4) different types of support—environmental resources and social influences.

Conclusions

This study highlighted the importance of organisational factors in knowledge translation in fall prevention. The findings emphasise the importance of leaders’ role and style in providing a supportive culture and contextual factors during the knowledge translation process. This study provides an understanding of the knowledge translation and sustainability of evidence-based practice and the Otago exercise programme for fall prevention programmes for community-dwelling older adults in Norway.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12913-020-05853-8.

Determinants of an evidence-based practice environment: an interpretive description

Background

Despite the available research to inform nursing practice, many patients still fail to receive evidence-based care. Several evidence-based practice (EBP) models have been developed to guide nurses through the steps in the process, yet these models have not been uniformly adopted or consistently used. The original purpose of this research was to gather perspectives and experiences of nurses using the Iowa Model of EBP to help inform its introduction into other practice settings. As a more in-depth understanding was gained, the emphasis of the study shifted towards understanding the determinants of the EBP environment.

Method

The study was conducted in an 800-bed comprehensive academic medical centre in the USA with a 25-year history of using the Iowa Model of EBP. Semi-structured in-depth interviews were conducted with twelve nurses from various roles to ascertain their perspectives and experiences using the model. The interview transcripts were reviewed alongside relevant published literature and internal documents in a process of synthesising, theorising, and conceptualising. Data were collected during the first half of 2019.

Results

Four determinants of the local EBP environment were identified from the perspectives and experiences of participants: (1) the importance of a shared model to guide staff through the EBP process; (2) support for EBP in the form of education, hands-on training, and knowledge infrastructure; (3) active team facilitation by direct care nurses, nurse managers, nurse specialists, and nurse scientists; and (4) a culture and leadership that encourages EBP.

Conclusion

Introducing an EBP model is an essential first step for an organisation to improve consistent and reliable evidence-based care; to be most effective, this should be done in conjunction with efforts to optimise the EBP environment.

Development, implementation and evaluation of an evidence-based practice model in a new hospital in Chile

AIMS

To describe an implementation programme for an evidence-based practice (EBP) model in a new Chilean hospital and to analyse the programme evaluation results.

BACKGROUND

Evidence-based practice is key to professional nursing for improving health care safety and quality.

METHODS

First, a literature review was performed to develop an institutional EBP model. Second, internal and external analyses contributed to assessing facilitators for and barriers to implementation. Third, a multi-stage implementation plan was conducted. Fourth, process and outcome indicators were evaluated.

RESULTS

The model considered the basic elements of EBP and outlined different decision-making levels in clinical practice. Several facilitators for implementation were identified. Each implementation stage included activities addressing EBP knowledge, attitude and skills. Outcome indicators showed significant improvement regarding knowledge (p = .038). Providers with formal EBP training, compared with providers without training, showed a significant difference of 8.6% (0.6 points) in the average CPBE-19 score in knowledge, attitude and application in the last evaluation (p < .01).

CONCLUSION

Having an EBP programme with ongoing implementation strategies improves knowledge over time, and formal training enhances positive results.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers can build an institutional research culture to improve the quality of care using an EBP programme that fits organisational needs.

EBP 2.0: Implementing and Sustaining Change: Implementing Improved Central Line Flushing Practices

This is the eighth article in a series about evidence-based practice (EBP) that builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step-published between 2009 and 2011 (to access the series, go to http://links.lww.com/AJN/A133). This follow-up series features exemplars illustrating the various strategies that can be used to implement EBP changes-one of the most challenging steps in the EBP process.

Development and Psychometric Testing of the Implementation Self-efficacy for EBP (ISE4EBP) Scale

There is inadequate research about nurses’ confidence in implementation strategies that foster the application and sustainability of evidence-based practice (EBP). Guided by Bandura’s self-efficacy theory, we propose that self-efficacy (confidence) in EBP implementation strategies can accelerate the uptake of evidence into practice to improve health care quality. The purpose of this study was to develop and test the psychometric properties of the Implementation Self-efficacy for EBP (ISE4EBP) scale as a measure for evaluating self-efficacy in using EBP implementation strategies. In a sample of 65 registered nurses, the 29-item ISE4EBP scale demonstrated adequate content validity (via content validity index), internal consistency reliability (Cronbach's alpha = 0.987), and construct validity indicated by associations with organizational readiness for EBP. Clinicians may use the ISE4EBP scale to identify areas for building implementation confidence to accelerate the uptake of evidence to improve quality care.

Experiences of evidence-based practice mentors: a phenomenological study

Background: The importance of the role of clinical nursing leaders as Evidence-based Practice (EBP) mentors has increased; however, information regarding their experiences is limited. Aims: This study aimed to explore EBP mentors' lived experiences. Design: This qualitative study used a phenomenological framework suggested by Colaizzi. Methods: The participants were seven EBP mentors working as unit managers in Korea. Data were collected via in-depth, semi-structured interviews. Findings: The experiences of EBP mentors were identified to three categories: 'challenges in taking on the new role of EBP mentor', 'forming intimate EBP mentor-staff nurse relations' and 'becoming independent as a facilitator'. The EBP mentors experienced role ambiguity, stress, and burden during the initial phase of EBP mentorship; however, they adjusted and reported positive experiences during the adjustment process. Conclusion: Before implementation an EBP initiative, systematic and educational programs that target the EBP mentors should be offered. A systematic approach to creating an institutional culture of EBP are also needed.

The tensions between micro-, meso- and macro-levels: physiotherapists' views of their role towards fall prevention in the community - a qualitative study

BACKGROUND

Falls are a global public health concern. Physiotherapists are a key resource in this context, but there is sparse knowledge about how they perceive their role in the primary care setting. Therefore, the purpose of the present study is to explore physical therapists' (PTs) view of how they experience and perceive their role working with fall prevention in a community care setting.

METHODS

Semi-structured interviews were conducted with 17 physiotherapists. Data were analysed using a qualitative thematic analysis.

RESULTS

The analysis resulted in a core theme and three subthemes. The core theme was 'capability to cope with the tensions between the micro-, meso- and macro-levels in fall, prevention', which indicated the importance of an evolving multifaceted, evidence based and innovative physiotherapy role. A key factor for this role is to take an integrative biopsychosocial approach based on how biological and psychosocial factors are uniquely related in fall prevention. The three themes were as follows: 1) always moving and changing: the competent explorative knowledge-hungry clinician's multifaceted role; 2) multiprofessional - but in the end alone; 3) reaching out - from the bottom to the top. Success in the role of physiotherapists in fall prevention depends on the empowering leadership and working culture, as well as on the time and multifaceted professional competence of the clinicians.

CONCLUSION

Our findings indicate that the PTs' role reflects their abilities to change and improve their professional work in accordance with evidence based knowledge. To ensure good quality the PTs focused on the special needs of the patients, evidence-based fall prevention, interdisciplinary team work, good clinical competences, good skills in communication, and interpersonal relations. Attention should be placed on the importance of biopsychosocial perspective framing in the actual clinical and political context. The PTs saw the need for working at the micro-, meso- and macro-levels to succeed in the work of fall prevention.

Strategies for the successful implementation of disinfecting port protectors to reduce CLABSI in a large tertiary care teaching hospital

Disinfecting port protectors are a supplement to the central line-associated bloodstream infection prevention bundle as an optional recommendation from the Centers for Disease Control and Prevention. Despite evidence of effectiveness, few centers have successfully reported systematic, sustained implementation of these devices. In this article, we discuss a successful implementation in a large tertiary care teaching hospital, using an evidence-based, multidisciplinary approach. Infection prevention; Bacteremia; Ethanol caps; Bundle measures; Quality improvement; Hub infection.

Humanitude in the humanization of elderly care: experience reports in a health service

OBJECTIVE

To describe the experience in the implementation of the Humanitude Care Methodology (MCH) in the humanization of care for the elderly.

METHODOLOGY

This is an experience report about the implementation of the MCH, in a Health Service in Portugal, with capacity for 30 elderly people, most of them having cognitive alterations.

RESULTS

The implementation of the MCH has shown positive results in the humanization of care for the elderly, namely in the reduction of agitation behaviors and better acceptance of care. There was a change in organizational culture, more focused on the person and on the humanization of care.

CONCLUSION

The results reflect the need to introduce innovative care methodologies in the training of health professionals, with a focus on interaction, for a professionalized relational care that dignifies the person cared for and the care giver.

CE: Original Research: Exploring Clinicians' Perceptions About Sustaining an Evidence-Based Fall Prevention Program

: Purpose: This study aimed to address the knowledge gap between implementing and sustaining evidence-based fall prevention practices for hospitalized patients by exploring perspectives of the interprofessional health care team.

DESIGN

A qualitative design was used to capture insights from clinicians across disciplines in a large midwestern academic medical center.

METHODS

Four homogenous semistructured focus groups and three individual interviews involving a total of 20 clinicians were conducted between October 2013 and March 2014. Audio-recorded data were transcribed and analyzed using inductive qualitative analysis.

FINDINGS

Two primary themes emerged from participants regarding the sustainability of an evidence-based fall prevention program: communication patterns within the interprofessional health care team and influences of hospital organizational practices and elements. Several subthemes also emerged. Participants gave nursing staff primary responsibility for fall risk assessment and prevention.

CONCLUSIONS

Individual professional perceptions and practices, as well as organizational characteristics, affect the sustainability of evidence-based fall prevention practices. While all team members recognized patient falls as a significant quality and safety issue, most believed that direct care nurses hold primary responsibility for leading fall prevention efforts. The data support the importance of effective interprofessional team communication and organizational practices in sustaining an evidence-based fall prevention program across inpatient units. Furthermore, the data call into question the wisdom in labeling quality indicators as "nursing sensitive"; the evidence indicates that a team approach is best.

De-implementation of tradition-based practices in critical care: A qualitative study

AIM

To explore the process of tradition-based practice (TBP) de-implementation by critical care nurses.

BACKGROUND

Ritualistic and routine practices have been described as sacred cows or TBPs. Many clinical practices have insufficient or no evidence and may lead to poor patient outcomes. De-implementation (termination) of potentially harmful, ineffective, or non cost-effective TBP is necessary to facilitate evidence-based practice (EBP) in the clinical setting.

DESIGN

Descriptive qualitative inquiry guided this study.

METHODS

Twenty-two critical care nurses from an acute care hospital in central Florida participated. Individual and focus group interviews were performed March to July 2016 and analysed using thematic analysis.

RESULTS

Three themes were identified: (a) uncertainty, (b) desire to know, and (c) preparing for practice change. Nurses were uncertain about the scientific underpinnings of everyday clinical practices and had difficulty differentiating TBP from EBP. De-implementation processes and strategies appeared to replicate implementation processes.

CONCLUSION

More research is needed to evaluate de-implementation processes and strategies used for de-implementation. An emphasis should be placed on ensuring that nurses are knowledgeable about fundamental EBP skills to encourage assessment of clinical practices for supporting research evidence. Awareness and understanding of TBPs will facilitate a more comprehensive approach towards achieving the gold standard of EBP.

The Development of a Pediatric Medication Administration Guideline for Preprocedure Nurse Callers

PURPOSE

This article describes the authors' development of a pediatric medication administration guideline for use by preprocedure nurse callers. Preprocedure refers to procedures done with general anesthesia such as surgery, endoscopy, or magnetic resonance imaging.

DESIGN

This article describes a process improvement project.

METHODS

The literature was searched using Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Google Scholar, and Google. No existing peer-reviewed pediatric preprocedure medication administration guidelines were found. A guideline with instructions for commonly prescribed pediatric medications was developed.

FINDINGS

Use of the guideline improves patient safety by providing clear medication administration instructions, while increasing the efficiency and autonomy of our nurse callers. Surveys of the nurse callers demonstrated that the guideline was clear, caregivers were receptive to receiving instructions from nurse callers, and use of the guideline decreased the number of calls made to other providers.

CONCLUSIONS

The use of a medication administration guideline improves patient safety, nurse efficiency, and nurse autonomy.

The Teach Back Project: A System-wide Evidence Based Practice Implementation

PURPOSE

Teach-back is an evidence-based strategy identified as a cornerstone intervention for improving communication during healthcare encounters. Evidence supports the use of teach back with patients and families to improve understanding of discharge instructions and supporting self-management. There is significant evidence that staff do not routinely use teach-back while communicating with patients and families.

DESIGN AND METHODS

This evidence-based practice project examined the impact of a brief educational intervention for a multidisciplinary staff on knowledge of health literacy and the use of teach-back during patient-education. Clinical staff working at a 290 bed Magnet® designated Midwest pediatric healthcare organization attended a 45-60 min, standardized, instructor led interactive teaching session about the impact of low health literacy, the use of open ended questions and how to use teach-back with patients and families. Pre and post education surveys, and a one-year sustainability survey were administered.

RESULTS

Over 300 multidisciplinary team members (including acute care, emergency room, and surgical nurses, dieticians, respiratory care practitioners and occupational and physical therapists) participated in the education and surveys. Both nurses and non-nurses demonstrated increased knowledge of the teach-back process and reported high rates of clarifying information and correcting misunderstandings when using teach back with patients and families. Qualitative data revealed clarifications are often about medications and skill-based treatments.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Teach-back is a valuable strategy that can improve the safety and quality of health care and supports the National Action Plan to Improve Health Literacy.

Conduction, Evaluation, and Future Considerations for an Obesity Educator Training Program in Korea

To reduce the prevalence of obesity and provide information on evidence-based obesity treatments, the Education Committee of the Korean Society for the Study of Obesity (KSSO) has developed and launched the first Obesity Educator Training Program (OETP). After the course, we analyzed the results of a survey from 110 participants, comprising medical doctors (n=58), nutrition specialists (n=19), exercise specialists (n=14), and students (n=6). Approximately half of the participants were recruited through the Internet (48%), followed by academic leaflets, such as conference posters (21%); the reasons for participation were to learn about evidence-based treatments for obesity (47%), to receive up-to-date knowledge on obesity treatments (39%), to obtain basic information on obesity (10%), and others (4%). More than half of the participants found the date, lecture time, process, and theme of the OETP favorable. The participants indicated that there should be an in-depth course, sharing of the presented files with attendees, a longer lecture time, and a broader OETP that includes other specialties such as nursing. To improve the OETP, the educational committee of the KSSO must develop an in-depth OETP that will reflect these participant's feedback.

CE: Oral Care for Head and Neck Cancer Symptom Management

: An evidence-based practice change at a radiation oncology center in a large academic medical center was designed to reduce the severity of oral mucositis in adults receiving radiation treatment for head and neck cancer. In the intervention described, patients were given newly created oral care kits and educational materials to improve their oral hygiene. Evaluations were conducted at three points during the project (before radiation treatment, during week 4 to 5 of treatment, and one month after treatment). At week 4 to 5-when the severity of oral mucositis is expected to peak-patients reported improved oral hygiene practices and reduced oral mucositis severity. The authors conclude that the use of these oral care kits and educational materials lessened the effects of oral mucositis during and after radiation treatment.