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:
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 RNAO’s (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 evidencebased 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 club.
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
average.
May 22, 2006 MLA Annual Conference
2
Collaboration
Jackson Memorial Hospital
Louis Calder
Memorial Library
May 22, 2006 MLA Annual Conference
3
Topic Overview
EBN Strategic Plan
Educational Strategies
Practice Strategies
Organizational Strategies
Outcomes
Challenges
Future Plans
May 22, 2006 MLA Annual Conference
4
Resources (3)
Assess Environmental
Readiness for Evidence
Based Practice Culture (1)
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
May 22, 2006 MLA Annual Conference
5
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
May 22, 2006 MLA Annual Conference
6
Timeline for EBN Curriculum
May 2004 Intro class: Finding the EvidenceIntroduction 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
Orientation
January 2006 Certificate Program in EBN
Developed
January 2006 UM Research Certification Class
May 22, 2006 MLA Annual Conference
7
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)
May 22, 2006 MLA Annual Conference
8
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
May 22, 2006 MLA Annual Conference
9
Ovid MEDLINE/CINAHL
Tutorials
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 searching
Shows how to get articles online,
from the shelf, or via Interlibrary
Loan
May 22, 2006 MLA Annual Conference
10
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 &
procedures
Established Nursing Practice Councils including
Standards Council and Quality Research & EBP
Council
May 22, 2006 MLA Annual Conference
11
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 survey
Results shown on slides 13-21
May 22, 2006 MLA Annual Conference
12
Barriers to Research Utilization
16.4%
Lack of skill accessing/assessing research
7%
Research Not Valued
41.8%
Lack of Time
11.1%
Unaware of Scope of
Autonomous Nursing Practice
23.6%
Lack of resources
May 22, 2006 MLA Annual Conference
N=1033
13
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%
May 22, 2006 MLA Annual Conference
14
Nursing Knowledge of
Evidence Based Practice
YES
Answer to “I have ….”
Accessed full text, evidence-based
electronic nursing/medical journals from the
Louis Calder Memorial Library (N = 636)
NO
5
30.2%
69.8%
Accessed a Clinical/Best Practice Guideline via 4
internet (N = 592)
43.2%
56.8%
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)
3
24.9%
1
75.1%
58.4%
0
20
May 22, 2006 MLA Annual Conference
41.6%
40
60
80
100 %
15
Nursing Knowledge of
Evidence Based Practice
The 2004 ANA standards of practice require
all registered nurses to: utilize evidence3rd Qtr
based assessment techniques, evidencebased interventions and treatments specific to
the patient.
60.5%
The highest level of evidence in the “Pyramid
2nd Qtr
of Evidence” is considered to be systematic
reviews and meta-analyses.
The best way to define evidence-based/best
1st Qtr
practice is utilization of the most current and
valid research combined with clinical
expertise and patient preference.
32.4%
61.8%
0
20
May 22, 2006 MLA Annual Conference
40
60
80
100
16
EBP Skill: PICO Writing
Used the “PICO” framework to form my research question
12.1%
P = Patient Problem
I = Intervention
C = Comparison
O = Outcome
"PICO"
87.9%
YES
NO
0
25
50
May 22, 2006 MLA Annual Conference
75
100
17
Journal Consultation & Practice Change
Consulted journal article regarding clinical question
Changed practice due to a new research finding
60
50
40
52.5%
15.3%
31.7%
30
16.8%
20
16.7%
15.3%
9.1%
10
0
Within
the last
3 months
Within
the last
6 months
21.2%
21.3%
Within the
Last year
More than
2 years ago
May 22, 2006 MLA Annual Conference
Never
18
Cultural Context of Leadership
85.1%
77.8%
77.6%
75.1%
68.7%
68.4%
63.3%
62.9%
61.3%
59.1%
52.9%
My work place is highly task driven
The workplace culture is a learning organization that values individuals and
their contribution to client care
My manager’s expectations of me are clearly defined
Life long continuous learning is highly valued by nursing leadership
Organizational nursing values & beliefs are clearly defined in my workplace
Performance evaluation relies on multiple sources and multiple methods for
evaluation
On my unit, the educational philosophy is best characterized as enabling
My manager’s approach to learning, teaching and managing is empowering
Nurse leaders are visible and accessible to all levels of nursing
Organizational nursing leadership embraces change and encourages my
input in the decision making
Technical nursing skills are more highly valued than critical reflection and
critical thinking skills
May 22, 2006 MLA Annual Conference
19
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 research
Higher rate of practice change based on evidence
Higher rate of knowledge about EBP
Comprehensive, collaborative approaches to
educational strategies for EBP
May 22, 2006 MLA Annual Conference
20
Survey Conclusions (continued)
Pravikoff study
Jackson study
The value of research was
considered the secondhighest barrier to EBP
Able to define EBP 46%
Access to electronic resources
36%
Used research reports to
support their practice
42%
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
69%
May 22, 2006 MLA Annual Conference
21
Focus for Improvement
Increase utilization of “PICO” format for research
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
May 22, 2006 MLA Annual Conference
22
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; 31:317-22.
ASSESS need for
change in practice
DEVELOP an answerable research question
EVALUATE
IMPLEMENT
CONSULT best evidence resources
EDUCATE
SYNTHESIZE best evidence
PROPOSE/DESIGN change
in practice/policy
to go to relevant committee
May 22, 2006 MLA Annual Conference
STIMULATE inquiry
23
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 membership
May 22, 2006 MLA Annual Conference
24
Nurse Week May 2005
May 22, 2006 MLA Annual Conference
25
Educational Outcomes
497 nurses attended
Introduction to EBP class
80 nurses attended either
MEDLINE/CINAHL search
tutorials
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
May 22, 2006 MLA Annual Conference
26
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.”
May 22, 2006 MLA Annual Conference
27
CINAHL session searches
Cumulative Index Nursing Allied Health Literature
14,367
16000
14000
12000
10000
8000
6000
4000
1,067
2000
0
2004
2005
May 22, 2006 MLA Annual Conference
28
Practice Outcomes
Policy and Procedure Committee using JHS EBP Model &
EBP resources to update policies and procedures
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
May 22, 2006 MLA Annual Conference
29
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
May 22, 2006 MLA Annual Conference
30
Challenges
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
May 22, 2006 MLA Annual Conference
31
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 CEU’s 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 knowledge—from
the nursing school curriculum to the hospital
32
May 22, 2006 MLA Annual Conference
Thank You
Tanya Feddern
Reference & Education Services Librarian
Louis Calder Memorial Library,
University of Miami Miller School of
Medicine
tfeddern@med.miami.edu
305-243-6648
Kathryn Ewers
Nursing Educator
Jackson Memorial Hospital in Miami,
Florida
kewers@um-jmh.org
305-585-7134
May 22, 2006 MLA Annual Conference
33
References
CITI: Course in the Protection of Human Research Subjects
https://www.citiprogram.org/citi_information.asp
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://www.um-jmh.org/perfimp/EBP2/EBP2.htm
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. No.9.
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. rnao.org/best 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.
May 22, 2006 MLA Annual Conference
34
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): 84-93.
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): 180-91.
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 OctDec.
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.
May 22, 2006 MLA Annual Conference
35