Implementation of an evidence-based practice program
The pool of medical workers who graduated more than a decade ago actually increases every year, and whether we like it or not, they may have missed a lot of medical updates and new practices during their time in clinics or academia. A medical professional has to stay updated with the latest trends and practices in the medical field because he may be able to use these trends in treating and administering proper plans of care to his patients. Evidence-based practice has the potential to improve overall patient outcomes because it uses valid, researched, and tested evidence that serve as options for medical professionals (ABIEBR, 2011). Medicine has a long history; there have always been different treatment plans for different cases with varying degrees of effectiveness. This helps the medical professional choose the best treatment for his patient in a valid and evidence-based way.
Most medical professionals today resort to using evidence-based practice whenever they feel they are facing a rather complex case. Simple cases are reinforced with evidence so that a more positive patient outcome can be obtained. The effectiveness of using evidence-based practice in the field of medicine and rehabilitation is proven to work. Nurses review and look for evidence from the thousands of journal articles and studies published from different universities every year. However, there are many skills a nurse needs to learn before being able to search for and use this evidence quickly and effectively (Fink, Thompson, & Bonnes, 2005). Hospital management should provide training sessions and seminars for their staff relating to the use of evidence-based practice and its effectiveness in treatment and rehabilitation. In addition, it should encourage medical professionals in all departments to use evidence in treating their patients so that errors from treatment-directed techniques will decrease. The treatments that the nurses will implement are already tested, so the medical professionals will have no need to perform further tests. Topics during seminars and training sessions for EBPT should include how and where to look for evidence (access). Nurses from the hospital should also be able to learn how to differentiate research study designs and critically appraise an article (Beyea & Slattery, 2006). Use of EBPT for treatment and rehabilitation should lead to patient and client satisfaction.
This paper will therefore describe in details the implementation of an EBP program within the settings of a hospital organization whereby it will focus on the rationale for the change, the audience that needs convincing on the need for the change, the benefits of EBP to the organization, identify the group that will spearhead the change, the proposed timeline and the measures of success of the change program.
Body
Implementation of an evidence-based practice program is the proposed change. The program is intended to instill an organizational culture of the use of evidence-based practice treatments in the management of all patients with the aim of improving patient outcomes. Evidence-based practice refers to a conscientious, explicit problem-solving approach employed in the delivery of healthcare which incorporates a clinician’s expertise with the best available clinical evidence from research and the preferences or values of a patient (Sackett et al, 1996, p.72). Best available evidence in this case is used in reference to external research which is clinically relevant and patient centered. Such research is normally conducted in the basic sciences of medicine on issues such as the efficacy of treatment modalities, accuracy of diagnostic tests amongst others. Evidence-based findings from external clinical research invalidate, replace or improve on the existing treatments and/or diagnostic tests. Clinical expertise on the other hand means the adeptness acquired by individual clinicians by virtue of their clinical experience and practice. Improved clinical expertise is reflected by one, more appropriate and accurate diagnosis, two, identification and utilization of effective and efficacious management modalities and three, an increased sensitivity to patients’ preferences and values when making decisions on their care.
Instillation of an organizational culture of the use of evidence-based practice in the management of patients portends significant benefits for patients, health care workers and the institution. In particular, evidence from an array of studies indicates that EBP improves the quality of care and in effect patient outcomes and satisfaction. In addition, the EBP approach has been shown to increase the skills of health care practitioners, job satisfaction and job retention (Madigan, 1998, Melnyk, 1999, Roberts & Yeager, 2004 as cited in Wallen, 2010). It also optimizes the delivery of health care, reduces variations in practice and the costs associated with health care by for instance lowering the incidence of adverse reactions, malpractice insurance premiums as well as those due to high staff turnovers. However, despite the aforementioned potential benefits, the incorporation of EBP into everyday clinical practice remains largely inconsistent and low. This is because such integration poses a significant multifaceted challenge to the health care organization. Barriers to implementation of EBP include inadequate knowledge, lack of informatics and EBP skills by health care practitioners, misconceptions about EBP, inadequacy of resources, lack of administrative support and lack of adequate educational preparation on how to use evidence from clinical research(Fineout-Overholt et al., 2005, Pagoto et al., 2007, Pravikoff et al., 2005 as cited in Wallen, 2010). The change process is therefore intended to identify and breakdown these barriers to the utilization of EBP in the management of patients. In addition, current trends indicate that in future, reimbursements for health care services will be made only for those care services provided according to EBP. As such, instillation of a culture of use of EBP is of great importance for the future financial existence of the organization because it will equip the hospital management with a bargaining chip when negotiating with medical insurers.
Implementation of EBP can be done at the individual or system level. A number of individual and system approaches such as the Clinical Scholar Model by Schultz (2005 as cited in Wallen, 2010) and the Iowa model by Titler (2002 as cited in Wallen, 2010) for the implementation of EBP have so far been developed. For the planned change, the Advancing Research & Clinical Practice through close Collaboration framework by Melnyk & Fineout-Overholt (2002) model would be used to guide the change process. This model was conceptualized by Melnyk in 1999 as a mentorship model for assisting the implementation of EBP by nurses in advanced practice. However, for the proposed change, its 2002 version which was adjusted to serve as guide for implementation and sustenance of EBP at the system level will be used. The first step of the ARCC framework entails the assessment of organizational culture and readiness for the implementation of EBP with an aim of identifying the facilitators and barriers to EBP as well as the development of a plan to for overcoming these barriers. After this, EBP mentors are identified, developed and strategically placed in the organizational system so that they can work directly with the staff at the points of delivery of care fostering their knowledge, skills and beliefs in EBP. Findings from studies have shown that EBP mentors play a crucial role in strengthening the beliefs of staff in EBP as well as in enhancing their ability in implementing it. This is especially critical in view of findings by other studies which have indicated that there is better implementation of EBP when the beliefs in it are strong (Melnyk et al., 2004). EBP mentors are normally the staff responsible for leading and mentoring nurses throughout the nursing department such as nurse managers, clinical educators and specialists, nurse researchers amongst others. Other factors that have been shown to contribute to the success of EBP implementation change strategies other than individual knowledge, skills and beliefs about EBP, EBP mentors include administrative support, skills in informatics, availability of resources and journal clubs.
The benefits of an organizational cultural shift towards EBP include improved patient outcomes reflected as a decrease in the incidence of adverse events, a reduction in the rates of infection and in the length of inpatient stays amongst others. Implementation of EBP also potentially improves the knowledge and skills of the health care staff and in effect the quality of care provided to the patients. EBP implementation has been shown to increase the job satisfaction of nurses as well as enhance group cohesion. An improvement in group cohesion and job satisfaction in turn leads to a decrease in nurse turnover rates. This lowers the costs that the organization would have incurred in recruiting, hiring and conducting orientations for new nurses (Melnyk et al., 2004). The EBP related improvements in patient outcomes would also greatly minimize the costs of providing health services. This is especially so considering that EBP improves patient safety by greatly reducing the number of adverse events. Adverse events have been shown to be quite costly for hospitals and for medical insurance companies who have to provide reimbursements for patients involved. One study established that the total costs for an adverse event was $58 766. These costs include those incurred due to extra hospital stays needed and other inpatient expenses, outpatient expenses and future medical expenses. In addition, the institution may incur litigation costs incase such clients decide to sue. As such, implementation of EBP would help to lower malpractice premiums (Mello, Studdert & Thomas, 2008). Therefore although the organization would incur certain costs in implementing the cultural change, in the long run, these would be compensated for and surpassed by the cost benefits that EBP would bring.
As previously mentioned, the planned cultural shift would be implemented using the ARCC model which would entail the selection and training of a group of senior nurses to provide mentorship to the nurses who provide the actual care. Members of this group would be drawn from nurse managers, nurse educators, clinical nurse specialists and nurse educators from all departments. This group was chosen because they are the ones normally charged with the responsibility of mentoring and leading the other nurses. As such, once they are trained on EBP they can easily educate the nurses in their departments, monitor and evaluate their progress. In addition, it would be easier to provide ongoing skill building and mentorship activities to the group. The selection of this group is also informed by the findings of studies which have concluded that persons who strongly believe in and have skills in EBP are likely to not only to implement it but also to teach others about it. As such, training of the mentors on nursing beliefs and skills is hoped to translate to increased belief in and higher levels of skill in EBP and its associated benefits (Menylk et al., 2004). Additionally, the decision on having nurse leaders acting as mentors champion the paradigm shift was also based on the benefits of mentorship in nursing which are well documented in varied literature. Mentorship in nursing is construed to be an effective strategy for orienting nurses into a new system, providing them with support whenever there are changes to be made to existing practices, to improve their quality of care and scholarly productivity (Barker, 2006; Greene et al., 2006).
The proposed timeline for the implementation of the planned change is seven months. The first step in the implementation phase will be to identify the mentors to spearhead the change process. The identified nurse champions will then be taken for a two days workshop where they will be oriented and trained on the basic skills and knowledge they need to initiate, implement, evaluate and sustain EBP. The nurse leaders will then be required to provide mentorship to nurses in their respective units. Follow up consultation boosters will then be provided for the nurse champions and the teams in every unit monthly for the seven months duration of the change program. Evaluation of the impact of the program would be undertaken at the beginning and at end of the seven months.
The outcomes measures of success of the program would evaluate the achievement of the benefits of implementation of EBP cited previously that is increased job satisfaction amongst nurses, increased retention of nurses, increased beliefs in EBP, enhanced group cohesions and lastly the level of implementation of EBP. Evaluation of these parameters would be done prior to the implementation of the EBP program and at the end of the program following which their scores would be compared. A number of scales will be utilized in measuring the achievement of the various benefits. The Organizational Culture and Readiness for System-wide Implementation of EBP (OCRSIEP) by Fineout-Overholt and Melnyk (2006 as cited in Wallen, 2010) would be used to assess the readiness of the organization and the organizational culture for implementation of EBP. This scale measures 25 items on a 5-point scale akin to the Likert scale. The responses range from “not at all to very much” (Wallen, 2010). High scores indicate that the organization is ready for the implementation of EBP. The EBP Beliefs Scale by Melnyk and Fineout-Overholt (2003) will on the other hand be used to tap the individual beliefs of staff on EBP. This scale comprises of 16 items designed to assess an individual’s beliefs on EBP as well as their ability to implement it. Similar to the OCRSIEP, the 16 items are measured using a 5-point Likert-like scale with options ranging from 1 (strongly disagree) and 5 (strongly agree). A high score for this scale will therefore reflect enhanced positive beliefs on EBP.
The EBP implementation scale (EBPI) also by Melnyk & Fineout-Overholt (2003) will be used to evaluate the level of implementation of EBP practices. The scale has 18 items and respondents will be required to indicate the number of times they have engaged in a particular EBP during the previous 8 weeks. High total scores for this particular scale will indicate increased use of EBP knowledge and skills. Reported job satisfaction of nurses would be measured using the 7-item Job Satisfaction Questionnaire by Price & Mueller (1981 as cited in Wallen, 2010). It also measures responses on a 5 likert-like scale with lower total scores reflecting higher job satisfaction and vice-versa. Cowin’s (2002 as cited in Wallen, 2010) Nurses Retention Index will be used to measure the intention of nurses to leave or stay within the profession. It has 8 items for which responses for every item are arranged on an 8-point likert-type scale which ranges from 1 (definitely false) to 8 (definitely true). High scores in this particular scale indicate increased retention levels. The level of group cohesion in terms of aspects such as attitude and judgment would be assessed using the group cohesion scale by Good & Nelson (1973 as cited in Wallen, 2010). This tool has 6 items whose responses are measured on a 7-point Likert-like scale. Low total scores for this scale will indicate higher group cohesion and vice-versa.
Conclusion
In summary therefore, implementation of an evidence-based program which is meant to instill an organizational culture of the use of EBP in the management of all patients is the proposed change. EBP portends great promise on patient outcomes, mitigation of costs, knowledge and skills of the staff and compliance with standards hence there is an urgent need for its implementation. For this change to take place, a host of players to include the hospital administration, nurse leaders, academic and professional institutions affiliated to the organization and the nurses need to be convinced the benefits of a paradigm shift towards EBP. Reduction of costs, improvements in quality of care and patient outcomes, a decrease in nurse turnover rates are some of the potential benefits of EBP to the institution. Nurse leaders constitute the group chosen to champion this change because they are ones who normally provide leadership and mentorship to the other nurses. The proposed timeline for the implementation of this change is seven months. Lastly, the measures of success for the planned change will include nurses’ retention, their application of EBP knowledge and skills, their beliefs in EBP amongst others. These parameters will be measured using a number of scales such as the EBP beliefs scale and their scores compared with the baselines obtained at the beginning of the program.
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