Delphi Study of APNs’ EBP Competencies IndicatesConsensus among EBP nurse experts in Finland

Hannele Saunders, PhD, MS, MPH, APRN-BC, CNS, CNRNResearch Manager, Xamk University of Applied Sciences

Post-Doctoral Researcher, University of Eastern Finland, Faculty of Health Sciences, Dept. of Nursing Science

Disclosuren Author: Hannele Saunders, PhD, APRN-BC, CNS, CNRNn Employer: Xamk University of Applied Sciencesn Learner objectives: The learner will be able to:

1) Describe the differences in the EBP competencies of RNs and APNs developed by Melnyk et al. (2014)2) Compare and contrast the EBP competencies of RNs and APNs in

Finland and the USA

n The author has no conflicts of interestn No sponsorship or commercial support was given to the

author

Presentation Overviewn Delphi Study of APNs’ EBP Competencies Indicates

Consensus among EBP nurse experts in Finland – Background– Aims– Methods– Results– Conclusions– Next Steps– Take-Home

n Questions and Comments

Delphi Study of APNs’ EBP Competencies: Background

§ Systematic implementation of evidence-based practice (EBP) has been shown in many research studies to effectively improve the quality and consistency of care and patient outcomes; however, nurses do not consistently use evidence in practice

§ The first sets of research-based, essential EBP competencies for nurses were developed through 2 separate national consensus processes in the USA focusing on: § Assessing practicing nurses’ capabilities to implement EBP (Melnyk et al.

2014) § Providing guidance for EBP professional development and education

programs in nursing (Stevens 2009)

Delphi Study of APNs’ EBP Competencies: Backgroundn This Delphi study utilized (with permission) the 24 EBP competencies for

practicing RNs and APNs developed by Melnyk et al. (2014)

n These EBP competencies for practicing RNs and APNs were published in 2014 in an original article in the Worldviews on Evidence-Based Nursingentitled:– Melnyk, B.M., Gallagher-Ford, L., Long, L.E. & Fineout-Overholt, E.

(2014). The Establishment of Evidence-Based Practice Competencies for Practicing Registered Nurses and Advanced Practice Nurses in Real-World Clinical Settings: Proficiencies to Improve Healthcare Quality, Reliability, Patient Outcomes, and Costs. Worldviews on Evidence-Based Nursing 11(1), 5-15.

– Handout of Table 7: EBP competencies of the above-referenced article

Why are nurses’ EBP competencies important?§ Expertly developed and validated EBP competency sets:

§ Help guide nurses in consistently providing evidence-based care to patients

§ Allow healthcare delivery organizations to outline a uniform practice standard for nurses to attain related to EBP

§ EBP competency sets outline to nurses how to engage in EBP and base their practice decisions on best available evidence, thus helping nurses consistently integrate EBP into their daily care

§ The implementation of standardized EBP competency sets in clinical practice therefore promotes the attainment of improved care quality and patient outcomes, which are priority goals for most healthcare organizations

Delphi Study of APNs’ EBP Competencies: Aims§ The primary aims of this Delphi study were to:

§ Explore the views of a panel of Finnish expert nurses

§ Highlight divergent perceptions and opposing views among the panelists

§ Establish consensus about the key content of the essential EBP competencies developed by Melnyk et al. (2014) for practicing professional Registered Nurses (RNs) and Advanced Practice Nurses (APNs) in the Finnish healthcare environment

§ The study sought to answer the following research question:

§ ‘What are the Finnish expert nurse panel’s ratings of how essential are the 24 EBP competencies for practicing professional RNs and APNs in the healthcare delivery settings in Finland?’

Delphi Study of APNs’ EBP Competencies: Methodsn This study utilized an Argument Delphi design, which is a modified Policy

Delphi study design– Focuses on bringing up for discussion among the panelists diverse justified perspectives on

the topic of interest– Adheres to the main goal of the traditional Delphi method, which strives to establish group

consensus from individuals’ opinions, i.e., reach unanimity within a group

n The Argument Delphi method is available as an open source code Internet application (https://www.eDelphi.org)– Was used for this study to anonymously conduct the virtual panel discussions and

commenting of the essential EBP competency statements in a closed discussion group on the Internet

n The virtual Delphi panel consisted of a purposive sample of 14 Finnish RNs, including nurse managers and leaders, APNs, APN students, and nurse educators employed at 7 large healthcare delivery organizations and educational institutions across Finland, some of whom also served as EBP mentors in their respective organizations

Delphi Study of APNs’ EBP Competencies: Methodsn The data were collected in Nov-Dec 2017 from 14 RNs and APNs participating

in the virtual Delphi panel at the eDelphi website over two rounds of the virtual Delphi panel, each lasting 10 days and conducted anonymously

n A snowballing approach was utilized to draw the virtual Delphi panel of nurses with a special interest in EBP, who: – Received an email invitation to participate in the Delphi panel with a brief explanation of the

purpose of the study and the Argument Delphi method to be utilized in the study

– After the contacted potential RN and APN panelists expressed interest in becoming members of the virtual Delphi panel, an email containing a cover letter with a direct link to the virtual Delphi panel at the eDelphi website was sent to them

– Previous research results indicate that inquiring potential panelists’ interest ahead of time increased their buy-in as panel members and decreased their attrition from the subsequent rounds of the panel

n A reminder e-mail was sent to non-responding invited panelists during the week following the initial invitation

Delphi Study of APNs’ EBP Competencies: Methodsn During the first round of the virtual Delphi panel, the panelists were presented with a

Finnish translation of Melnyk et al.’s (2014) 13 EBP competency statements for practicing RNs and 11 additional EBP competency statements for practicing APNs, questions on demographics and EBP experience, and detailed instructions for participating in the Delphi panel

n The panelists were asked to rate each EBP competency statement as “To what extent do you believe the above EBP competency is essential for practicing registered professional nurses?” on a 5-point Likert-type rating scale, where the ratings ranged from 1= not at all, 2 = a little, 3 =somewhat, 4=moderately so, and 5=very much essential

n The panelists were also asked to justify their views on each of the EBP competency statements by writing open-ended comments on each of the statements in the box provided

Delphi Study of APNs’ EBP Competencies: Methods§ After the closing of the first round, the facilitator of the virtual Delphi panel provided a

brief summary of the first round’s results for the panelists to view at the eDelphiwebsite

§ The EBP competency statements for practicing RNs and APNs on which consensus had not yet been reached, were revised to reflect the comments and suggestions provided by the Delphi panelists

§ The second round of the panel started immediately on the day following the closing of the first round, as previous research results indicated that taking advantage of the forward momentum was important while the panel discussions were still fresh in the panelists’ minds

§ The EBP competencies for practicing RNs and APNs developed by Melnyk et al. (2014) were translated according to the World Health Organization’s processes for translation and adaptation of research instruments (WHO 2010) from American English into Finnish and demographics were modified to the Finnish cultural context

Delphi Study of APNs’ EBP Competencies: Resultsn A total of 14 Finnish RNs and APNs participated in the Delphi panel during

both rounds of the panel

n The panelists’ average age was approximately 48 years, and their average length of work experience in nursing was approximately 24 years

n Almost one-half (45%) of the panelists were nurse clinicians, while over one-third (36%) worked as nurse educators, and almost one-fifth (18%) were nurse leaders

n The essential EBP competencies for practicing RNs consist of 13 EBP competency statements, while the essential EBP competencies for practicing APNs comprise the 13 EBP competencies for RNs plus the additional 11 EBP competencies specifically addressing the professional role responsibilities of APNs (Melnyk et al. 2014)

Delphi Study of APNs’ EBP Competencies: Resultsn Of the 13 essential EBP competencies for practicing RNs, consensus was

established among the Delphi panelists during the first round on all but EBP competency number 6, when evaluated against the criteria for establishing consensus – The EBP competency statements were rated at a group median score of 4-5 among 70% of

the participants and an inter-quartile range IQR≤1.0n The median score was used as the measure of central tendency because it is

considered to be more robust to the effect of outliers than the mean, and the inter-quartile range (IQR) was used as a measure of distribution – These measures were selected because they are commonly recommended measures in the

international literature to determine consensus in Delphi studiesn If consensus was not reached or the EBP competency statements were

considered unclear in the first round of the Delphi panel, the statements were reworded to reflect the comments and suggestions of the Delphi panel

Delphi Study of APNs’ EBP Competencies: Resultsn As to EBP competencies numbers 3, 5, 7, and 9 for RNs, many panelists

expressed comments to the effect that these EBP competencies for RNs required knowledge and skills at such a level that they should be EBP competencies for APNs, not all RNs

n As to EBP competency number 1 for RNs, ‘the majority of the panelists viewed ‘questioning’ as important but not sufficient, as nurses must also possess knowledge of truly effective clinical practices, i.e., evidence-based education is also necessary

n As to EBP competencies numbers 8 and 9 for RNs, the panelists viewed them as important but very difficult to apply to practice, as the current healthcare information systems in many Finnish healthcare delivery organizations are not supportive in providing the type of internal evidence needed to implement these EBP competencies as basis for clinical practice decisions

Delphi Study of APNs’ EBP Competencies: Results§ As to EBP competency number 13 for RNs, ‘the majority of the panelists

viewed the competency as the responsibility of every healthcare professional, not just the responsibility of nurse leaders

§ Of the 11 additional essential EBP competencies for practicing APNs, consensus was established among the Delphi panelists during the first round on all but EBP competency number 21

§ As to the EBP competencies numbers 15, 16, 19, 20, 21, and 23 for APNs, many panelists emphasized that these EBP competencies should be implemented in collaboration with other experts, such as university researchers or national-level stakeholders, e.g., the authors of national clinical practice guidelines and best practice recommendations

Delphi Study of APNs’ EBP Competencies: Resultsn During the second round of the Delphi panel, the group median for the reformulated

EBP competency number 6 for RNs only reached 3 although the IQR was <1.0, i.e., although agreement had been achieved among the panelists on this EBP competency, the median score did not reach the threshold value of a group median score of 4-5 outlined in the criteria for establishing consensus

– The panelists were in agreement that this was an essential EBP competency, but for APNs, not for all RNs, particularly considering the early stage of development related to both the APN roles and systematic EBP implementation in Finnish healthcare delivery settings

n Consensus was also achieved on the reformulated EBP competency for APNs number 21 during the second round of the Delphi panel, as the group median score was 4 and the IQR was ≤1.0

n A high degree of consensus existed among the Delphi panelists about the overallcomprehensiveness of the EBP competency statements developed by Melnyk et al. (2014)

Delphi Study of APNs’ EBP Competencies: Conclusions§ A panel of Finnish nurses including APNs, educators, leaders, and APN

students reached consensus with minor modifications on all but one (#6) of the essential EBP competencies for practicing professional RNs and APNs, thereby endorsing and validating internationally the EBP competencies developed and published by Melnyk et al. (2014) in the USA

§ The Finnish nurse panelists’ comments on the EBP competency #6 for RNs reflected 2 main issues: § 1) The majority of the panelists viewed this EBP competency demanding such an advanced

competency level that it should be an EBP competency for APNs, not all RNs

§ 2) The panelists viewed critical appraisals of (single) published research studies as insufficient evidence to change best practices, i.e., that a broader body of evidence is required as the basis for changing established clinical practices

§ Interestingly, the EBP competency # 6 for RNs was the same EBP competency that in the original Delphi study (Melnyk et al. 2014) required dividing into two separate EBP competency statements for sufficient clarity

Delphi Study of APNs’ EBP Competencies: Conclusions§ In summary, the comments of the Finnish Delphi panelists on the essential

EBP competencies for practicing RNs and APNs reflected some of the cultural,

societal, and contextual differences between the healthcare delivery systems and environments in Finland and the USA

§ These differences included:

§ An emphasis on seeking group consensus in decision-making

§ A focus on collaboration with others vs. appreciating individual initiative and leadership

§ The influence of the divergent professional role responsibilities and autonomy of RNs and

APNs in Finland and the USA

§ The early stage of development and implementation of the APN roles in the Finnish healthcare delivery system in comparison to those in the USA, were repeatedly revealed in the panelists’ comments

§ However, the essential EBP competencies (Melnyk et al. 2014) were internationally endorsed and validated with minor modifications for use in a

European country with a different linguistic and cultural environment, healthcare delivery system, and practice context than those in the USA

Delphi Study of APNs’ EBP Competencies: Next Steps

n As previous studies have shown that nurses do not consistently use evidence in practice, nurse managers, leaders, and educators should first focus onimproving clinicians’ EBP competencies, i.e., advancing their readiness and capabilities for integrating best evidence into their daily practice– National consensus-based, clinical practice-oriented EBP competency sets provide

an excellent mechanism for achieving this goal– They establish a standard of practice for nurses to achieve related to EBP and

provide guidance for nurses in integrating best evidence into their daily practice, which in turn facilitate broad-based, more consistent implementation of EBP in daily care delivery

n There is an urgent need for the development, implementation, and evaluation of a joint EBP competency set for all healthcare professionals, i.e., an interdisciplinary set of EBP competencies that can be used by all practicing healthcare professionals from any healthcare discipline, including nursing

Delphi Study of APNs’ EBP Competencies: Take-homen Knowledge of the basic EBP principles and skills to apply the steps of the

EBP implementation process to daily practice are essential competencies for all nurses to enable them to provide highest-quality care and improve patient outcomes and to systematically engage in EBP

n As the endorsement and validation of the essential EBP competencies internationally underscores the ideas that – EBP is a shared competency– The steps of the EBP implementation process are universal, i.e., applicable to all

healthcare disciplines, there is a continued need for the international endorsement and validation of the essential EBP competency sets in other countries and healthcare disciplines

n The results of this Delphi study provided such an endorsement and international validation, through establishing consensus with minor modifications among the members of a diverse Finnish nurse expert panel about the key content of the essential EBP competencies developed by Melnyk et al. (2014) for practicing professional RNs and APNs at Finnish healthcare delivery settings

Questions or Comments? Thank you

”Knowing is not enough; we must apply.Willing is not enough; we must do.”

Goethe

Read More About It:n Melnyk, B. M., Gallagher-Ford, L., Zellefrow, C., Tucker, S.,Thomas, B., Sinnott, L.T. & Tan, A.

(2018). The First U.S. Study on Nurses’ Evidence-Based Practice Competencies Indicates Major Deficits That Threaten Healthcare Quality, Safety, and Patient Outcomes. Worldviews on Evidence-Based Nursing 15(1), 16-25.

n Melnyk, B.M., Gallagher-Ford, L. & Fineout-Overholt, E. (2016). Implementing the EBP competencies in healthcare: A practical guide for improving quality, safety, & outcomes. Sigma Theta Tau International, Indianapolis, IN.

n Melnyk, B. M., Gallagher-Ford, L., Thomas, B. K., Troseth, M., Wyngarden, K. & Szalacha, L. (2016). A study of Chief Nurse Executives indicates low prioritization of evidence-based practice and shortcomings across hospital performance metrics across the United States. Worldviews on Evidence-Based Nursing 13(1), 6-14.

n Melnyk, B. M., Gallagher-Ford, L., Long, L. E. & Fineout-Overholt, E. (2014). The establishment of evidence-based practice competencies for practicing Registered Nurses and Advanced Practice Nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence-Based Nursing 11(1), 5-15.

Read More About It:n Melnyk, B., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The state of evidence-

based practice among U.S. nurses. Journal of Nursing Administration, 42, 410-417.

n Melnyk, B.M., & Fineout-Overholt, E. (Eds.) (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd Ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

n Saunders, H. & Vehviläinen-Julkunen, K. (2018a). Healthcare professionals’ evidence-based practice competencies: An overview of systematic reviews. Worldviews on Evidence-Based Nursing, accepted.

n Saunders, H., Gallagher-Ford, L. & Vehviläinen-Julkunen, K. (2018b). Endorsement and validation of essential evidence-based practice competencies for practicing nurses in Finland: An Argument Delphi study. Worldviews on Evidence-Based Nursing, submitted.

n Saunders, H. & Vehviläinen-Julkunen, K. (2018c). Key considerations for selecting instruments when evaluating healthcare professionals’ EBP competencies: A discussion paper. Journal of Advanced Nursing, Early View Publication ahead of Print.

Read More About It:n Saunders, H. & Vehviläinen-Julkunen, K. (2017). Nurses’ evidence-based practice beliefs and the

role of evidence-based practice mentors at university hospitals in Finland. Worldviews on Evidence-Based Nursing 14(1), 35-45.

n Saunders, H., Stevens, K.R. & Vehviläinen-Julkunen, K. (2016a). Nurses’ readiness for evidence-based practice at Finnish university hospitals: A national survey. Journal of Advanced Nursing72(8), 1863-1874.

n Saunders, H., Vehviläinen-Julkunen, K. & Stevens, K.R. (2016b). Effectiveness of an education intervention to strengthen nurses’ readiness for evidence-based practice: A single-blind randomized controlled study. Applied Nursing Research 31, 175–185.

n Saunders H. & Vehviläinen-Julkunen K. (2016c). Evidence-based practice and job-related nurse outcomes at Magnet-aspiring, Magnet-conforming, and non-Magnet university hospitals in Finland: a comparison study. Journal of Nursing Administration 46(10), 513-520.

n Saunders, H. & Vehviläinen-Julkunen, K. (2015). The state of readiness for evidence-based practice among nurses: An integrative review. International Journal of Nursing Studies 56, 128-140.