Laying the Foundations for Evidence-Based Practice for Nurse Residents

University of Health Systems Consortium (UHC) and the American Association of Colleges of Nursing (AACN) Established a post baccalaureate nurse residency program 1 year program run by an acute care hospital in collaboration with a partner school of nursing. Everyone must complete an EBP project Sends the message that EBP is an expectation for clinical practice and supports what are taught in their baccalaureate program

University of Colorado (UCH) This chapter describes the residency curriculum requirements related to EBP & provides samples of projects completed by nurse residents at UCH.

Background:

Government clearinghouses for clinical guidelines:1. Agency for Healthcare Research and Quality2. Institution of Medicine Sanctioned the use of EBP as the basis for all health-care delivery. Emphasized that practice supported by evidence improves patient outcomes and clinical practice.

Nursing Educators reported if evidence does not inform the nurses clinical judgment, nursing practice can become rapidly outdated and patient care can ultimately suffer. (Brancato 2006, p.195)

Definitions of EBP1. The integration of the best evidence available, nursing expertise, and the values and preferences of the patient and family. -- Sigma Theta Tau

2. The process of shared decision making between practitioner; patient; and others significant to the patient, based on research evidence. The outcome of this decision-making process should be person-centered, evidence-based care. Rycroft-Malone & Colleagues, and Sacker & Colleagues

It is necessary to gain commitment from both the individual nurses and the organization as a whole to create a culture of EBP. Creating this culture for nurses entering practice can be challenging. Strategies that are supportive and focus on removing barriers can demonstrate the value and relevance of EBP for nursing.

What Happens at UCH Polit & Beck: EBP provides an important framework for self-directed lifelong learning that is essential in an era of rapid clinical advances and the information explosion. New graduate nurses are in a prime position to both adapt to this framework and propagate the new culture. During the hiring process, new nurses at UCH receive a letter from the chief nursing officer (CNO) informing them of the expectations for using evidence in practice. The hospitals job descriptions, nursing philosophy and professional practice model all include expectations for EBP. EBP is the encompassing framework for the shared leadership model. When the councils and committees in the shared leadership model make decisions, it is an expectation that their decisions will be based on evidence. Policies and procedures are evidence-based and the level of evidence is documented. Organization supports Transformational Leadership in contrast to supporting command and control leadership. TL enhances the integration of evidence into practice.

Case Study by Stetler and Colleagues (2007) to understand organizations that seem able to find and use evidence at multiple levels in an ongoing, integrated fashion in contrast to those who do not. Purposive sampling of 2 contrasting cases/ nursing departments with 3 units in each department. One case was judged as role model per nomination process involving the American Organization of Nurse Executives. UCH was selected as the role model. Several findings were indicative of a supportive organizational EBP culture. They included: Included higher scores on the Practice Environment Scale, indicating more positive work environment. Visible behaviors included articulating a vision, setting expectations, role modeling, and direct participation of key leaders.

New graduates experience many stressors when entering practice supporting and teaching them to search, evaluate and apply research and best evidence to their practice helps them gain confidence early in their career. Anecdotal reports from new graduate nurses indicate utilizing evidence in practice and conducting EBP projects as part of their residency curriculum is an important experience. This is enhanced by sharing the project with their unit because it helped each nurse resident become a more integral part of the unit care team.

Nurse Residency EBP Curriculum

Research nurse scientist introduces new graduate nurses to EBP as early as day 2 of clinical orientation presents hospitals history of incorporating EBP & introduction to the hospitals Evidence-Based Multi-disciplinary Practice Model.

Resources to Support Evidence-Based Practice1. EBP council2. EBP champions on each unit3. Quarterly research grant rounds4. Unit-based journal clubs5. Access to facilitators: Clinical nurse specialists, educators, research nurse scientist, residency coordinator6. Unit-based access to library for searches7. Transformational nurse leaders8. Nurse informatics specialist who embed EBP protocols in documentation

Nurse residents attend 4-hour graduate nurse seminar each month month 7: attend an 8-hour course entitled EBP. Beyond the Basics presenters: CNO, director of professional resources, College of Nursing faculty and hospital-based research nurse scientists, and residency program coordinator provides an overview of the structure, process, and outcomes of utilizing EBP in an acute care magnet hospital. Actual examples are used Final Project: Literature Review to gather evidence on the chosen topic. Residents may choose to supplement the literature with their own data collection. May work independently or as a group Must disseminate findings by organizing a journal club for their unit, revise a policy or procedure, or present a poster at the program completion celebration. Progress of project is overseen by a resident facilitator Residency coordinator reviews multiple past projects completed by residents that were presented at regional and national conferences. Month 11: 2-hour EBP workshop To share project concerns, access resources in the computer laboratory, and continue to prepare for dissemination. Completion Celebration Showcase their EBP final projects to their peers and nursing leaders

Examples of Nurse Resident Evidence-Based Practice Projects

1. Resident Project: Medical Intensive Care Unit/ Surgical Intensive Care Unit

Moral Distress

Definition: The painful psychological disequilibrium that results from recognizing the ethically appropriate action, yet not taking it, because such obstacles as lack of time, supervisory reluctance, an inhibiting medical peer structure, institution policy, or legal considerations. (Cohen et al, 2001 p.250)

Studies ICU nurses frequently experience distress when questioning if the care they provide is morally right. Moral distress has been identified and studied in ICU nurses for over 2 decades and is a strong predictor of job satisfaction and retention. 2005 study: critical care nurses emerged as the group most at risk for experiencing moderate to severe moral distress (Elpern, Covert, & Kleinpell, 2005) 2001: 15% of nurses reported resigning a position due to experiencing moral distress (Corely et al 2001). 2004: Nurses report experiencing anguish, sleeplessness, nausea, migraine headaches, gastrointestinal upset, tearfulness, and a sense of isolation, but they are unable to identify these as the signs and symptoms of moral distress (Hanna, 2004). 2007: Among critical nurses, 41% met Becks Depression Inventory II criteria for clinical depression and 65% met the Pittsburgh Sleep Quality Index Criteria for poor sleeper (Pendry, 2007) The four most distressing situations that emerged from the literature were discordant expectations, role conflict, futile care, and end-of-life care. 2006: The AACN published recommendations and startegies for recognizing and dealing with moral distress. The most important way to cope with moral distress is for nurses to acknowledge it and to recognize its impact. The University of Colorado Hospital has implemented the AACN recommendations. The hospital utilizes ethics committees, a palliative care team, and standardized end-of-life protocols. Families are involved in decision making through family meetings. If an employee is experiencing feelings of distress, support and counseling are provided through the Employee Wellness Program.

Dissemination: Information wielded from the literature review for this project was disseminated in a poster presentation for the residents, nurse leaders, and incoming new graduates starting their first week in the ICU. The poster presentation was then displayed in the unit break rooms for senior nurses to review.

2. Resident Project: Orthopedics Unit/ Medicine Subspecialties UnitCultures of Pain

3. Resident Project: Perioperative UnitSurgical Attire Guidelines

Relevance of EBP to nursing practice

What areas of nursing practice might we want to ask EBP questions about?

You might ask questions about a range of categories of practice:1. Assessment how to properly gather and interpret findings?2. Causes of the problem how to identify them?3. Deciding what the problem is where the symptoms/signs indicate a range of possible problems how do you decide which is most likely? 4. How to select and interpret tests used to identify problems and to monitor patient progress?5. How to estimate the likely clinical progression of a condition/illness and any likely complications?6. How to select interventions that do more good than harm and that are worth the effort and cost of doing them?7. How to reduce the chance of the problem reoccurring or how to promote health?8. How to keep up to date; improve your skills; and run a more effective/efficient nursing team?9. How best to understand the perceptions of individuals and groups e.g. service users and carers

Why is best evidence and evidence-based nursing important? Ensures patient/clients receive the care that fits their needs Facilitates sound decision making and makes it more explicit Minimises risk to the patient/client so that benefits outweigh harm Provides the nurse with the skills and knowledge to evaluate healthcare literature and practice Exposes gaps in knowledge and conflicts in evidence

What is Evidence?

In the context of evidence based practice this is research published in professional and academic journals and systematic reviews of research found in databases of evidence (such as Cochrane). Knowledge derived from a variety of sources that has been found to be credible (Higgs & Jones 2000)

Evidence Classified by Level:

At least one systematic review of multiple, well designed randomised controlled trials (RCTs) At least one properly designed RCT of appropriate size Well designed trials without randomisation, single group pre-post, cohort, or matched case controlled studies Well designed, non-experimental studies from more than one centre or research group Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees

Other Forms of Evidence Evidence based on experiences (professional or personal) Evidence gathered from patients/clients and/or carers. Evidence based theory that is not research based.

What EBP is not EBP is not cook-book practice evidence needs extrapolation to the patients unique biology and values EBP is not cost-cutting practice when efficacy for the patient is paramount, costs may rise, not fall