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Implementation strategies for evidence-based practice: part III of a IV-part series on evidence-based practice.

In parts I and II of this series, the origins and definitions of evidence-based practice (EBP), the state of Nursing EBP readiness {RNFormation, August, 2010) as well as conceptual models of EBP {RNFormation November, 2010) were respectively explored. Part III in this series will present a brief overview of possible strategies for the implementation of EPB at the point of care.

While EBP is generally considered the expected standard in healthcare, despite decades of high-quality research and a growing evidence base, its impact at the point of care remains inconsistent (Adams & Titler, 2009). Multiple studies have demonstrated that the availability of high-quality research does not necessarily ensure that findings will be used to improve care at the actual point where that care is delivered, which in many situations, is the bedside (Clancy, Slutsky, & Appon, 2004; McGlynn et al., 2003; Institute of Medicine [IOM], 2001,2003, 2008).

To improve patient care, government agencies and individual organizations have focused time, attention and resources on compiling and evaluating research findings, as manifest by the increased numbers of systematic reviews and clinical practice guidelines (IOM, 2008), yet despite these efforts, EBP at the point of care remains less than desirable and some estimate that it takes up to 17 years from the time research is determined to be effective until its arrival and full utilization at the point of care (IOM 2007, 2008; Clancy & Cronin, 2005; Grimshaw et al., 2004; Wang et al, 2000; Srinivasan & Fisher, 2000; Taylor, et al, 1999). Studies both in the United States and Europe indicate 30% to 50% of patients do not receive evidence-based care, and 20%-25% of patients receive unneeded or potentially harmful care (Graham, et al., 2006; Mc Glynn, et al. 2003).

Clearly strategies to effectively implement EBP at the point of care are needed; however many barriers to implementing EBP have been described in the nursing literature, key among them are lack of knowledge, time, available resources, and administrative support (Estabrooks, 1998, Pravikoff, et al. 2005, Bondmass, 2008). Many institutions, due to a renewed emphasis on quality and safety, have created strategic initiatives for EBP 'on paper'; however for a truly supportive environment and an actual culture for EBP to exist at an institution, the leadership of the organization needs to incorporate EBP-related concepts into their mission. The mission for patient care services, for example, should ideally be operationalized to address: 1) the spirit of inquiry of the staff and the lifelong learning necessary for EBP as well as 2) the work environment that demands and supports nurses' accountability for practice and decision making and lastly the mission needs to 3) include a goal of improving patient care outcomes through evidence-based clinical and administrative decision making (Newhouse, et al. 2007).

Assuming a supportive environment addressing the requisites and barriers to EBP has been developed or is developing, what then are the process steps to the implementation of EBP? Although it may sound redundant, a reasonable first step for a practice based on evidence is to examine the evidence for successful EBP implementation. Nursing at Johns Hopkins Hospital and the Johns Hopkins University School of Nursing provides us with such evidence with their development and testing of the Johns Hopkins Nursing (JHN) Evidence-based Practice Model and Guidelines. The actual JHN model was discussed in a previous issue, the following discussion addresses the 'how-to' or the process of EBP.

The JHN EBP process can simply and straightforwardly be described with the acronym PET, which stands for Practice question, Evidence, and Translation. The process begins with the critical step of identifying a practice question. This initial step is crucial because how the question is posed drives the remaining steps in the process. After the question is determined, a search, synthesis, and appraisal of the evidence related to the question needs to be conducted. Based on the appraisal, a determination as to whether there is supporting evidence for a change or improvement in practice must then be made. If there is supporting evidence, the final step of translation occurs. In the translation step, practice change is planned for, implemented, evaluated, and results disseminated. The reader is referred to the actual Johns Hopkins EBP texts (Newhouse, et al, 2007, Poe & White, 2010) for more specific details, however a summary of the PET steps in the JHN EBP process are presented in Table I.

A brief exemplar adapted directly from Newhouse, et al. 2007, pp 173-176) might be useful to illustrate the PET steps.

Practice question: Prior to 2007, patients at the Johns Hopkins Hospital's post anesthesia care unit (PACU), were routinely required to void prior to discharge regardless of type of surgery, anesthetic technique, or associated risk factors. This resulted in holding patients unnecessarily in the PACU, increasing their length of stay, increasing costs, and possibly impeded the flow of patients from the operating room to the PACU. Because the problem related to a population of patients, a team was assembled to conduct an EBP project. The team consisted of 14 experienced PACU nurses (from 3 PACUs) of various clinical levels, an educator, and a manager. The nurses were supported by School of Nursing faculty, a nurse researcher, and two nurse administrators experienced in standards of care and performance improvement. The practice question was posed as: For adult ambulatory surgery patients, does discharge from PACU prior to voiding versus discharge from PACU after voiding result in increase urinary retention?

Evidence: The Standards for the American Society of Peri Anesthesia Nurses (ASPAN) were reviewed, but the standards did not directly address this issue. An extensive literature search was conducted finding 100 articles pertinent to voiding, but only 26 were applicable to this particular question. Individual nurses were assigned specific articles and a critique tool was used for each article. The American Society of Anesthesia, as well as 17 national teaching hospitals were contacted to determine their policy on this issue. All available evidence was rated for methodology and quality; the entire evidence search and appraisal process was overseen by a nurse researcher/mentor. Subsequent recommendations were categorized in three levels (low risk, moderate risk, and high risk) for urinary retention based on patient history, anesthesia, or surgery. Low-risk ambulatory adult patient can be safely discharged prior to voiding. Although moderate-risk patients may be 'dischargable' with instructions to return within 6- 8 hours if they have not voided, there was not enough evidence to make a recommendation. High-risk patients should void prior to discharge.

Translation: The PACU team supported the policy change that low-risk patients can be safely discharged, and moderate and high-risk patients should void prior to discharge. The PACU discharge criteria were modified to reflect the EBP recommendations. PACU staff received education on the evidence and implications. Along with clear voiding instructions given to patients at discharge, a next-day patient phone follow-up was added to the protocol. Since the guidelines were implemented [and up until the publication of the Newhouse, et al. text] no problems with urinary retention or return to the emergency room related to bladder distention were reported. In addition to the organizational impact on care, this project was used as an exemplar to illustrate the EBP process for ASPAN as the Society developed its EBP model.

Presented in this issue was a brief introduction to strategies for implementing EBP at the point of care. Following implementation of EBP efforts, an evaluation of our initiatives also needs to be accomplished and reported. In part IV of this EBP series, (featured in the next issue of RNFormation), evaluation of implemented innovations and program evaluation will be discussed.

Due to the limited space, complete references used in this article (20) are available only upon request, but any reader interested in the JHN EBP texts are referred to Sigma Theta Tau, International at to purchase: Johns Hopkins Nursing Evidence-based Practice: Model and Guidelines by Robin Newhouse et al., 2007 and Johns Hopkins Nursing Evidence-Based Practice: Implementation and Translation by Stephanie Poe & Kathleen M. White, 2010.

Interested readers are also directed the Health Care Innovations Exchange, a free database sponsored by the Agency for Health Care Research and Quality (AHRQ) for practice question ideas, implementation strategies, and detailed examples of many EBP projects conducted both system-wide and at the unit level

By Mary Bondmass, RN, PhD, CNE, Associate Professor of Nursing, School of Nursing, University of Nevada Las Vegas
Table 1: The Johns Hopkins Nursing Evidence-based
Practice Process

(Newhouse, et al., 2007, p. 202)


 Steps 1-5: Identify an EBP question
 Define the scope of the practice
 Assign responsibility for leadership
 Recruit an interdisciplinary team
 Schedule a team conference

EVIDENCE Steps 6-10: Conduct an internal and external
 search for evidence
 Appraise all types of evidence
 Summarize the evidence
 Rate the strength of the evidence
 Develop recommendations for change
 in systems or processes of
 care based on the strength of the

TRANSLATION Steps 11-18: Determine the appropriateness and
 feasibility of translating
 recommendations into a specific
 practice setting
 Create an action plan
 Implement the change (pilot testing
 as a preliminary evaluation
 is advised)
 Evaluate outcomes
 Report the results of the
 preliminary evaluation to decision
 Secure support from decision makers
 to implement the recommended
 change internally
 Identify the next steps
 Communicate the findings
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Author:Bondmass, Mary
Publication:Nevada RNformation
Date:Feb 1, 2011
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