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Strategies for Creating an Evidence-Based Practice Nursing Culture


Strategies for Creating an Evidence-Based Practice Nursing Culture Tanya Feddern MLIS, AHIP, MOT, OTR/L Kathryn Ewers RN, BA, MEd Special thanks for layout and graphics: – PowerPoint PPT presentation

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Title: Strategies for Creating an Evidence-Based Practice Nursing Culture

Strategies for Creating an Evidence-Based
Practice Nursing Culture
  • Tanya Feddern
  • Kathryn Ewers
  • RN, BA, MEd
  • Special thanks for layout and graphics
  • John D Jones Jr and Sandra Benitez

  • Project Abstract
  • Title Strategies for creating an evidence-based
    practice nursing culture
  • Author(s)/Affiliation Tanya Feddern, AHIP,
    University of Miami Miller School of Medicine,
    Louis Calder Memorial Library, Miami, FL, Kathryn
    M. Ewers, Jackson Health Systems, Miami, FL.
  • Purpose/Setting/Participants/Resources The
    purpose of our project was to develop a strategic
    action plan to create a nursing culture that
    values and utilizes evidence-based practices for
    the delivery of nursing care. This paper
    summarizes how to identify and develop
    educational interventions for fostering an
    evidence-based nursing culture at a
    university-affiliated public hospital in Miami,
    Florida. These interventions were implemented via
    collaboration between nurse educators and a
    medical librarian.
  • Brief Description To evaluate nursing culture
    and readiness for evidence-based practice, the
    nurse educators utilized the PARIHS (Promoting
    Action on Research Implementation in Health
    Services) framework and adapted the RNAOs
    (Registered Nurses Association of Ontario) Action
    Template. A descriptive survey was developed
    from the PARIHS framework and was used to assess
    cultural readiness for evidence-based practice.
    The RNAO template was used for identifying
    educational interventions. The nursing educators
    and medical librarian then collaborated on
    targeted educational interventions, such as
    selecting evidence-based filters for Ovid CINAHL,
    creating a unique evidence-based practice (EBP)
    certificate program consisting of collaborative
    continuing education classes, and brainstorming
    on other educational activities for the busy
    nurse clinician and researcher, such as an EBP
    online discussion list and an online journal
  • Results/Outcome Inter- and intra-collaboration
    between nursing educators and the medical
    librarian have led to the successful creation
    and/or modification of educational assessments
    and interventions to bring about a change in
    nursing culture towards using EBP in clinical
    practice. Our survey results suggest that
    intensive educational strategies are resulting in
    a higher rate of evidence-based practice change,
    and that nurses knowledge and skills about
    evidence-based practice are above the national

Jackson Memorial Hospital
Louis Calder Memorial Library
Topic Overview
  • EBN Strategic Plan
  • Educational Strategies
  • Practice Strategies
  • Organizational Strategies
  • Outcomes
  • Challenges
  • Future Plans

Assess Environmental Readiness for Evidence Based
Practice Culture (1)
Resources (3)
Stakeholders (2)
Implementation of Strategies for EBP Culture (4)
Identify Implement EBP Model (5)
Evaluation (6)
Framework for the Strategic Plan EBP Culture
Implementation Model Adapted from RNAO Toolkit
Clinical Practice Guideline Implementation Model
Educational Strategies
  • Developed CE classes
  • Intro to Evidence Based Practice
  • OVID MEDLINE Tutorial
  • OVID CINAHL Tutorial
  • Practice Guidelines
  • Included Intro EBN Class in Nursing Orientation
  • Developed EBN Bookmark
  • Developed EBN Certificate Curriculum

Timeline for EBN Curriculum
  • May 2004 Intro class Finding the
    Evidence-Introduction to EBP as CE Class
    (initially just to Hospital Educators)
  • Fall 2004 OVID MEDLINE Tutorial as CE Class
  • January 2005 Intro to EBP added to Nursing
  • January 2006 Certificate Program in EBN
  • January 2006 UM Research Certification Class

EBN Certificate
  • Introduction to EBN Finding the Evidence
    (required) 1.5 CEU
  • Either OVID MEDLINE Tutorial OR CINAHL Tutorial
    2 CEU
  • Guidelines Class 2 CEU (required)
  • EBN Project (required)

Introduction to EBP Finding the Evidence
  • Led by Kathryn Ewers
  • Course Objectives
  • Goals of EBN
  • Types of Evidence
  • Introduced EBN model
  • Introduced accessing Evidence-Based Resources

  • Led by Tanya Feddern
  • Course Objectives
  • Reinforces the EBP principles discussed in the
    Introduction to Evidence-Based Practice class
  • Introduces building a strategy for systematic
  • Shows how to get articles online, from the shelf,
    or via Interlibrary Loan

Practice Strategies
  • Developed Cultural Readiness for EBP Survey
  • Adapted an EBN Implementation model for the
    Jackson Health System (JHS)
  • Targeted Nursing Policy and Procedure Committee
    for utilization of EBN model to update policies
  • Established Nursing Practice Councils including
    Standards Council and Quality Research EBP

Cultural Readiness for EBP Survey
  • Six months after the educational interventions
    started, Kathryn Ewers wished to take a snapshot
    of EBN at the Jackson Memorial Hospital
  • JUNE 2005
  • An online survey was developed from the Promoting
    Action on Research Implementation in Health
    Services (PARIHS) framework
  • 1033 nurses participated during the week-long
  • Results shown on slides 13-21

Barriers to Research Utilization
16.4 Lack of skill accessing/assessing research
41.8 Lack of Time
7 Research Not Valued
11.1 Unaware of Scope of Autonomous Nursing
23.6 Lack of resources
Resources consulted when participants had a
clinical question
Clinical Practice/Best Practice Guidelines 3.5
Patient 2
Cochrane Collaboration 4
Internet Resources 10
Members of Healthcare Team 49
Textbooks 11
Policies Procedures, Clinical Pathways/Care
Plans 11
Journals 13
Nursing Knowledge of Evidence Based Practice
Answer to I have .
Accessed full text, evidence-based electronic
nursing/medical journals from the Louis Calder
Memorial Library (N 636) Accessed a
Clinical/Best Practice Guideline via internet (N
592) Utilized an evidence-based filter in a
literature search (N 567) Accessed full text,
evidence-based electronic nursing/medical
journals from the Internet (N 813)

Nursing Knowledge of Evidence Based Practice
The 2004 ANA standards of practice require all
registered nurses to utilize evidence-based
assessment techniques, evidence-based
interventions and treatments specific to the
patient. The highest level of evidence in the
Pyramid of Evidence is considered to be
systematic reviews and meta-analyses. The best
way to define evidence-based/best practice is
utilization of the most current and valid
research combined with clinical expertise and
patient preference.
EBP Skill PICO Writing
Used the PICO framework to form my research
question P Patient Problem I Intervention C
Comparison O Outcome
Journal Consultation Practice Change
Consulted journal article regarding clinical
question Changed practice due to a new research
Within the last 3 months
Within the last 6 months
Within the Last year
More than 2 years ago
Cultural Context of Leadership
  • 85.1 My work place is highly task driven
  • 77.8 The workplace culture is a learning
    organization that values individuals and their
    contribution to client care
  • 77.6 My managers expectations of me are
    clearly defined
  • 75.1 Life long continuous learning is highly
    valued by nursing leadership
  • 68.7 Organizational nursing values beliefs
    are clearly defined in my workplace
  • 68.4 Performance evaluation relies on multiple
    sources and multiple methods for evaluation
  • 63.3 On my unit, the educational philosophy is
    best characterized as enabling
  • 62.9 My managers approach to learning,
    teaching and managing is empowering
  • 61.3 Nurse leaders are visible and accessible
    to all levels of nursing
  • 59.1 Organizational nursing leadership embraces
    change and encourages my input in the decision
  • 52.9 Technical nursing skills are more highly
    valued than critical reflection and critical
    thinking skills

Survey Conclusions
  • Large practice gap between access of clinical
    practice guidelines and use of guidelines
  • As compared to a similar survey by Pravikoff,
    Jackson surpasses national trends in
  • Access to electronic evidence-based resources
  • Strong commitment to the value of nursing
  • Higher rate of practice change based on evidence
  • Higher rate of knowledge about EBP
  • Comprehensive, collaborative approaches to
    educational strategies for EBP

Survey Conclusions (continued)
  • Pravikoff study
  • The value of research was considered the
    second-highest barrier to EBP
  • Able to define EBP 46
  • Access to electronic resources 36
  • Used research reports to support their
    practice 42
  • Jackson study
  • The value of research was considered a barrier to
    EBP 7
  • Able to define EBP 61.8
  • Hospital and remote access to electronic
    resources 100
  • Used research reports to support their practice

Focus for Improvement
  • Increase utilization of PICO format for
  • Develop strategies to increase utilization of
    clinical practice guidelines when nurses have a
    clinical question
  • Address nurses perception of lack of time as the
    number barrier to research utilization
  • Ensure adequate computer and Internet access
  • Develop web page with EBP resources
  • Address leadership issues where scores are low in
    cultural leadership context

Nursing Model for Implementing Evidence-Based
Practice Adapted from Mohide, EA and King, B.
Hamilton Health Sciences (HHS) EBN Model, which
was adapted from Rosswurm ML and Larrabee JH.
Image J Nurs Sch 1999 31317-22.
ASSESS need for change in practice
DEVELOP an answerable research question
CONSULT best evidence resources
SYNTHESIZE best evidence
PROPOSE/DESIGN change in practice/policy to go
to relevant committee
Organizational Strategies
  • Dovetailed Magnet EBP activities
  • Marketing - Nurse Week Activities
  • Pursued International Center Membership with RNAO
  • Nursing Vision and Strategic Goals include EBP
  • Nursing strategic goals aligned with Corporate
    Vision and goals
  • Partnered with academic centers
  • Web page development
  • Developing Unit-Based Practice Councils
  • Recruited JHS nurses for Sigma Theta Tau

Nurse Week May 2005
Educational Outcomes
  • 497 nurses attended Introduction to EBP class
  • 80 nurses attended either MEDLINE/CINAHL search
  • EBN Certificate Graduate
  • JHS nurses present at International conferences
    on EBP
  • More interest in publishing
  • 1st class of JHS nurses completes 1st course of
    UM School of Nursing Certificate in Research
  • 7JHS nurses now UM CITI Certified for research
    with human subjects
  • CINAHL searches increase
  • 1,067 in 2004
  • 14,367 in 2005
  • Several JHS nurses appointed as adjunct UM
    Nursing Faculty

Nurses Evaluations Comments
  • OVID MEDLINE Tutorial
  • An excellent presenter who showed a lot of
    interest in her field (subject matter).
  • Tanya gave a very clear, thorough and fun
    tutorial. I really learned a lot about how to do
    a proper search. Thank you.
  • Ovid CINAHL Tutorial
  • Normally these activities are not helpful. This
    one was.
  • EBN Intro
  • Well presented. I learned a lot. Hands on
    helpful, wonderful speaker.

CINAHL session searches Cumulative Index Nursing
Allied Health Literature
Practice Outcomes
  • Policy and Procedure Committee using JHS EBP
    Model EBP resources to update policies and
  • Best Practice Guidelines used to
  • Develop Falls Prevention Program
  • Change practice re Domestic Abuse Screening
  • Reduce Pressure Ulcer Prevalence in ICUs
  • JHS Nurses participating in reviewing Healthy
    Workplace Guidelines in collaboration with RNAO
  • Online Journal Club under development with UM
    Faculty JHS nurses

Organizational Outcomes
  • Nursing Vision and Strategic Goals endorse
    evidence-based practice and global leadership in
    evidence based practice
  • Anticipated improvement in quality of care and
    patient outcomes
  • Anticipated improvement in nurse satisfaction
  • More respect for nurses knowledge
  • ANA Magnet Standards met for EBP
  • JHS Nursing featured in local and international
    nursing publications
  • Interdisciplinary interaction and CEs (nurses,
    RTs, Pharmacists)
  • Increased collaboration between UM JHS

  • Time constraints- compressing class content
  • Coordinating schedules
  • Time Resources for Marketing
  • Content modifications of CE materials from
    physicians to allied health
  • Competing Corporate Agendas
  • Managing contact hours and paperwork
  • MyMedEd accessible only to JHS Staff
  • Computer literacy variability

Future Strategies
  • University-based listservs on EBP for Jackson
    Memorial Hospital (JMH) nurses
  • On-line/self study Course Development
  • On-line journal clubs
  • JHS webpage on research and EBP for nurses
  • Target utilization of EBN Model to Unit Based
    Councils for initiating practice change
  • Provide CEUs for Occupational Therapy, Pharmacy
  • Tie Clinical Advancement Ladder to EBP Education
  • Joint Conference offerings with RNAO, UM, JHS
  • Collaborating with the UM nursing school and
    nurse librarian to create a continuity of EBP
    instruction and knowledgefrom the nursing school
    curriculum to the hospital

Thank You
  • Tanya Feddern
  • Reference Education Services Librarian
  • Louis Calder Memorial Library,
  • University of Miami Miller School of Medicine
  • 305-243-6648
  • Kathryn Ewers
  • Nursing Educator
  • Jackson Memorial Hospital in Miami, Florida
  • 305-585-7134

  • CITI Course in the Protection of Human Research
    Subjects https//
  • Estabrooks, C. A. (1998). Will evidence-based
    nursing make practice perfect? Canadian Journal
    of Nursing Research, 30, 15-36.
  • Ewers K. (2005) EBP Survey https//
  • Mohide, E. Ann., Coker E. (2005) Toward Clinical
    Scholarship Promoting Evidence-Based Practice in
    the Clinical Setting. Journal of Professional
    Nursing, Vol 21, No 6. 372-379.
  • Pravikoff, D., Tanner, A., Pierce, S., (2005).
    Readiness of U.S. Nurses for Evidence-Based
    Practice. American Journal of Nursing, Vol. 105.
  • Kitson, A., Harvey, G., McCormack, B. (1998).
    Enabling the implementation of evidence based
    practice A conceptual framework. Quality in
    Health Care, 7(3), 149-158.
  • Registered Nurses Association of Ontario. (2005).
    Shaping the future of nursing RNAO nursing best
    practice guidelines. Retrieved March 5, 2005 from
    www. practices
  • Registered Nurses Association of Ontario (2002).
    Toolkit Implementation of clinical practice
    guidelines. Toronto, Canada Registered Nurses
    Association of Ontario.
  • Sackett, D. L., Straus, S. E., Richardson, W. S.,
    Rosenberg, W., Haynes, R. B. (Eds.). (2000).
    Evidence-based medicine How to practice and
    teach ebm. Toronto Churchill Livingston.

Further Reading
  • Brown D. McCormack B. Developing postoperative
    pain management utilising the Promoting Action
    on Research Implementation in Health Services
    (PARIHS) framework. Worldviews on Evidence-Based
    Nursing. 2005 3rd Quarter 2(3) 131-41.
  • Donaldson NE. Rutledge DN. Ashley J. Outcomes of
    adoption measuring evidence uptake by
    individuals and organizations. Worldviews on
    Evidence-Based Nursing. 2004 3rd Quarter 1
    Supplement 1 S41-51.
  • Ellis I. Howard P. Larson A. Robertson J. From
    workshop to work practice an exploration of
    context and facilitation in the development of
    evidence-based practice. Worldviews on
    Evidence-Based Nursing. 2005 2nd Quarter 2(2)
  • O'Halloran P. Martin G. Connolly D. A model for
    developing, implementing, and evaluating a
    strategy to improve nursing and midwifery care.
    Practice Development in Health Care. 2005 4(4)
  • Rycroft-Malone J. The PARIHS framework--a
    framework for guiding the implementation of
    evidence-based practice. Journal of Nursing Care
    Quality. 19(4)297-304, 2004 Oct-Dec.
  • Wallin L. Profetto-McGrath J. Levers MJ.
    Implementing nursing practice guidelines a
    complex undertaking... including commentary by
    Rycroft-Malone J. Journal of WOCN. 2005 Sep-Oct
    32(5) 294-301.