Planning for implementation of evidence-based practice

Expectations for evidence-based healthcare are growing, yet the most difficult step in the process, implementation, is often left to busy nursing leaders who may be unprepared for the challenge. Selecting from the long list of implementation strategies and knowing when to apply them are a bit of an "art," matching clinician needs and organizational context. This article describes an application-oriented resource that nursing leaders can use to plan evidence-based practice implementation in complex healthcare systems.     

Evidence-based practice needs evidence-based implementation

Clinical pathways have been designed to provide an effective interface between evidence and practice in healthcare. Strong evidence supports the assertion that when clinical pathways are utilized they improve outcomes. However, published evidence measuring the uptake of clinical pathways by health professionals remains sparse. This article presents a study evaluating the degree of documented compliance with the clinical pathway chart used for patients diagnosed with an acute myocardial infarction (AMI) in a major Australian regional hospital. The relationships between compliance and demographic and illness were also examined. Data were collected from 124 records with the result that the level of documented compliance was 16.5%. Clients with private health insurance had significantly higher documented compliance with the clinical pathway than those with no private health insurance. There were also significant variations in documented compliance according to the type of AMI recorded. Recommendations to improve compliance with clinical pathways are included along with recommendations for future research.     

Pressure ulcers: implementation of evidence-based nursing practice

AIMS: A 2-year project was carried out to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines. This paper describes the implementation of the project and lessons learned. The evaluation and outcomes of implementing clinical practice guidelines to prevent and treat pressure ulcers will be reported in a separate paper. BACKGROUND: The prevalence and incidence rates of pressure ulcers, coupled with the cost of treatment, constitute a substantial burden for our health care system. It is estimated that treating a pressure ulcer can increase nursing time up to 50%, and that treatment costs per ulcer can range from US$10,000 to $86,000, with median costs of $27,000. Although evidence-based guidelines for prevention and optimum treatment of pressure ulcers have been developed, there is little empirical evidence about the effectiveness of implementation strategies. METHOD: The study was conducted across the continuum of care (primary, secondary and tertiary) in a Canadian urban Health Region involving seven health care organizations (acute, home and extended care). Trained surveyors (Registered Nurses) determined the prevalence and incidence of pressure ulcers among patients in these organizations. The use of a computerized decision-support system assisted staff to select optimal, evidence-based care strategies, record information and analyse individual and aggregate data. RESULTS: Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinary team. Lack of visible senior nurse leadership; time required to acquire computer skills and to implement new guidelines; and difficulties with the computer system were identified as barriers. CONCLUSIONS: There is a need for a comprehensive, supported and sustained approach to implementation of evidence-based practice for pressure ulcer prevention and treatment, greater understanding of organization-specific barriers, and mechanisms for addressing the barriers.     

Improving the implementation of evidence-based practice: a knowledge management perspective

Experience of knowledge management initiatives in non-health care organizations can offer useful insights, and strategies, to implement evidence-based practice in health care. Knowledge management offers a structured process for the generation, storage, distribution and application of knowledge in organizations. This includes both tacit knowledge (personal experience) and explicit knowledge (evidence). Communities of practice are a key component of knowledge management and have been recognized to be essential for the implementation of change in organizations. It is within communities of practice that tacit knowledge is actively integrated with explicit knowledge. Organizational factors that limit the development of knowledge management, including communities of practice, in non-health care organizations need to be overcome if the potential is to be achieved within health care.     

NCLEX-RN success: evidence-based strategies

Evidence-based nursing requires that students think reflectively and use clinical inquiry to develop clinical reasoning and decision-making skills. Likewise, nursing students need a strategy to be successful in passing the NCLEX-RN. The authors identify strategies based on nursing research to facilitate student success. While learning the evidence-based nursing process, the student must begin to think like a nurse while answering clinical practice questions. Using the skills taught for evidence-based nursing can be a powerful tool to approach the NCLEX-RN and succeed.     

Nurses reclaiming ownership of their practice: implementation of an evidence-based practice model and process

This article describes a new model and process to implement evidence-based practice. This model builds on concepts from the Iowa Model of Evidence-Based Practice, the Stetler model, and Rosswurm and Larrabee's model. The new model focuses on the centrality and involvement of staff nurses in making evidence-based practice clinical changes. Two figures illustrate the model and the implementation process. A detailed case study based on the model is included. Barriers identified in the literature review are addressed in the case study. Implementation of this model creates opportunities for staff nurses to recognize ownership of their practice and their role in changing the practice setting to a culture of evidence-based practice.     

Support for evidence-based practice

OBJECTIVES: To discuss examples of the process for evidence-based practice (EBP) and suggest helpful mechanisms for its support. DATA SOURCES: Published review and research articles, textbooks, guidelines, and web sites. CONCLUSIONS: Evidence-based practice requires a step by step process. Obtaining resources for EBP is essential to identifying and implementing and/or sustaining clinical care based on the best evidence available. IMPLICATIONS FOR NURSING PRACTICE: Finding resources to conduct EBP activities is one of the more challenging aspects of this approach to maintaining and improving quality of clinical care. However, nurses have found creative ways to obtain needed resources to implement EBP.