Towards that goal, the Center embarked on an initiative to educate nursing professionals on the concept, project development and implementation of evidenced-based practice (EBP) protocols with the purpose of improving patient outcomes. While quality improvements can and do result from a variety of patient care interventions, evidence-based nursing practice is unique in that it is scientifically based and focused on the patient population being cared for in a particular facility. As a fundamental tenet of professional nursing, engaging in EBP projects with the purpose of improving the care we provide to those entrusted to us is of the highest order.
What is Evidence-Based Practice?
It is one where the purpose is to use existing evidence to identify the optimal way to deliver a particular nursing care intervention, in the environment in which the project is undertaken. EBP projects can be implemented in acute or long term care, hospices, home care or ambulatory care, wherever nursing care is delivered. It is important to realize that each organization is different and so practices must be tailored to fit a particular situation.
How is an Evidence-Based Practice Project developed?
Using the Iowa Model, Teams of two or three nurses start by recognizing that a problem exists and then delves into the current approach to determine where in the process or intervention impediments reside. This can be challenging but it is vital to developing a clear, concise problem statement, a key element of a successful EBP project. EBP teams conduct worldwide literature searches to discover what research findings, if any, exist in this area and learn where and how nurses in other facilities approach similar situations. The information is analyzed, compared to currently employed processes, and then the final practice guideline is developed. Implementation of the guideline then follows, with mid course corrections taking place as needed. Excellent clinical reasoning and judgment are hallmarks of this step. A thorough evaluation of the project takes place at the completion of the implementation phase. If results show improvement in patient outcomes, the final step is to ensure sustainability throughout the unit or organization.
Why is Evidence Based Practice so important?
The ultimate goal of an EBP project is to ensure better patient outcomes. Nursing care guidelines informed by scientific literature, based on objective clinical findings will improve patient care and outcomes. Each team is required to prepare a Red Report that details each phase of their project with particular emphasis on the outcome(s), thus expanding the body of knowledge, so that others may learn as well.
What makes an EBP project successful?
Often nurses that work closest to a patient or with a group of patients will identify a process, treatment or intervention which, if modified, could improve patient care. These “nurse leaders” discuss the issue with their unit colleagues and as consensus is reached will then reach beyond their immediate team to enlist others, perhaps physicians, pharmacists, social workers, physical therapists, respiratory therapists and others that provide care to that population. Once that is achieved, the next step is to generate interest on the part of their superiors to provide the support and resources to develop an EBP project. While the success of an EBP project can be achieved without an organization’s active support, those projects that take their projects to a successful conclusion have, for the most part, nursing and administrative leadership that has championed the project and provided the necessary resources in the form of time, funding, access to internal and external consultants and, very importantly, has communicated the value of the project to the entire organization.
To date a number of teams have completed their projects with notable outcomes, including guidelines developed by them now forming the basis for nursing care in that unit. Very importantly, organizational and nursing management practices also evolved significantly. Policies, procedures, care plans, assessment tools, documentation, staffing, and budgets were affected. In some cases entire programs were developed and staff hired, such as the one to provide childbirth education, where the most significant outcome was a reduction in the number of cesarean sections performed on graduates of the childbirth education course (20%) as compared to a comparable group of women (28%) who had not gone through the course in the same facility. A decidedly forward step was the hiring of an OB Educator and the expansion of the program.
In another project, a pain assessment tool was redesigned to better capture the non-verbal cues of cognitively impaired and/or frail elderly residents in a long-term care setting. Together with a standardized, interdisciplinary pain assessment guideline, cultural sensitization and retraining of the largely foreign born staff, and greater awareness of the issue, the facility was able to dramatically reduce barriers to prompts and improve pain assessment and management in this population. Facility policies have been revised to ensure nursing skill competency in the use of the pain assessment tool. There was a 71% improvement in completion of the Comprehensive Pain Assessment Form; 40% improvement in documentation of pain location; 60% improvement in monitoring for analgesic side effects using a pain monitoring flow sheet, which is validated on an ongoing basis, and compliance with documentation of pain assessment is monitored by monthly chart audits, demonstrating a 55% improvement in documentation of assessment of interventions that improve pain.
An innovative evidence based practice in a tertiary facility brought about far reaching changes in the design and renovation of their Neonatal Intensive Care Unit (NICU). Staff wanted to compare sound levels in the unit to the recommendations of the National Recommended Sound Levels before construction began on the planned single-family room units. As a result of the project, structural changes to improve sound abatement were built into the new design for the renovations (acoustical ceiling tiles, sound abatement air ducts and floor tiles, changes to lighting, and an integrated continuous sound monitoring system). The team also brought about operational changes (designated Quiet Time in the unit each day), behavioral modifications (talking in soft voices, no banging of isolette doors or writing on isolettes), and educational changes to increase awareness of the impact of sound on pre-term infants and neonates. The result was an overall reduction in the sound levels in the NICU of between four and six decibels. The EBP team continues to monitor sound levels through data collection and behavioral compliance with reminders and re-education, particularly of new staff.
Changes in organizational and nursing management practices can take many forms. Some are as simple as allowing EBP teams time to meet or time away to attend meetings off-site. Others are more tangible in terms of supplies, equipment, additional staffing, funding or other resources that actually cost the facility hard dollars. Ultimately, the most far reaching outcomes are when new policies and procedures are established or revised, which then allows the practice to be embedded and sustained within the culture.
Our experience has been that whenever patient care quality can be effectively and efficiently improved and particularly when the cost benefit of those changes can be demonstrated and realized, those responsible for the allocation of resources quickly adopt recommendations.