Collaboration And Evidence Based Care Discussion
Exemplar Kaltura Reflection Hello. My name is Mike Smith. This recording will focus on Making Evidence Based Decisions. According to Barret (who published on this topic in 2017), caring for individuals who live in remote areas of the country is a challenging proposition and as a result, policymakers, and health care organizations along with health care professionals are searching for resources, such as telehealth services, to promote health and wellness as well as independent self-care for patients. Issues including primary care and specialist access, availability of ancillary services and transportation to and from each appointment continue to be roadblocks that could affect patient outcomes. In this video, I will discuss one such patient, Patrick Lake, and attempt to provide an evidence-based care plan to outline a safe, realistic outcome. Let me share some information with you about Mr. Lake Mr. Lake is a 64 -year old veteran who has had a left above the knee amputation after a service related injury over 35 years ago. He presented one week ago to the clinic after he had chest pain and trouble breathing. Collaboration And Evidence Based Care Discussion
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These symptoms began one week prior to his appointment. He stated that he did not have a ride to come to the clinic and had little choices about emergency care due to inability to pay the co-pay. He was admitted and diagnosed with congestive heart failure. He was discharged with a plan of care to improve his safety and wellness outcomes by arranging for home health visits which will include physical therapy and nursing care. Mr. Lake lives at home with his wife Gloria who is concerned with this new diagnosis. He is unable to return for frequent follow up appointments and lives at least 50 miles away from the nearest rehabilitation facility. Gloria relates that this is a concern for her as it is a “long drive” to the hospital if anything should go wrong. Prior to discharge, Mr. Lake asked if there is “any other way that he could complete my follow up appointments other than coming in to the clinic?” He mentioned that he has reliable internet as well as a telephone landline and cell phone. Mr. Lake will be discharged to home with an electronic home blood pressure cuff and also with a Holter monitor. The event monitor will be worn for one week and data can be uploaded to a central cardiology department for analysis. Now, I will explain the ways in which an evidence-based practice model was used to help develop the care plan for Mr. Lake An interesting publication from 2017, written by Barret, describes that telehealth and telemedicine have been an evolving evidence-based practice (EBP) since the 1970’s. This allows primary care providers to contact their patients through a phone call or online and discuss any concerns and monitor progression of recovery and wellness, according to a developed plan of care. The modalities for Mr. Lake may include home blood pressure readings, heart monitors and medication reconciliation. Daily blood pressure readings are extremely important as Mr. Lake was placed on two new blood pressure medications after his recent hospitalization. Without close follow up, the potential for significant blood pressure changes could impact his overall health. For example, measuring hemodynamics allows providers to correctly titrate blood pressure medications in an attempt to maximize cardiac output. This is key in patients diagnosed with CHF and leads to more energy and better quality of life. Cardiac monitors provide caregivers with information about electrical activity of the heart during any given situation. Collaboration And Evidence Based Care Discussion
Event monitors allow individuals to mark incidents where they experience palpitations, pain or other symptoms by pressing a button on the device. These devices allow for avoidance of any other cardiac event. Next, I will reflect on which evidence was most relevant and useful when making decisions regarding the care plan The decision to implement a telehealth program for Mr. Lake is based out of necessity. His lack of transportation and long commute to the clinic would most likely cause missed appointments and possibly delay sufficient recovery. The 2017 reference to Barret supports my point that telehealth and telemedicine offer an innovative and exciting method to deliver care and maximize patient outcomes. Lastly, I would like to identify benefits and strategies to mitigate the challenges of interdisciplinary collaboration to care plan within the context of a remote team. Mr. Lake initially suggested alternatives to traditional follow up appointments due to limited transportation and his location. This demonstrated motivation on his part to initiate and maintain health and wellness. The benefits of the interdisciplinary collaboration were that the patient could receive on-going and consistent care by the caregivers, RN’s and physicians without having to travel a great distance. A couple of strategies to mitigate the challenges of interdisciplinary collaboration efforts include the use of an electronic health record system which all health care members can access and accurately monitor the patient findings and frequent communication with one another with the use of technology for the purposes of corresponding with one another such as via telephone, Skype, FaceTime, etc. The overall result with such collaboration of a remote team leads to better patient outcomes. In conclusion, evidence-based practice models provide frameworks to apply EBP across a variety of settings. It’s known that EBP models assist the baccalaureate prepared nurse with developing tailored plans of care by incorporating the most current and relevant research when making vital decisions about care. In addition, having the most current evidence along with the collaboration of an interdisciplinary team who communicate effectively leads to positive patient outcomes. AACN1903_291-300 16/7/08 09:05 PM Page 291 AACN Advanced Critical Care Volume 19, Number 3, pp.291–300 © 2008, AACN Selecting a Model for Evidence-Based Practice Changes A Practical Approach Anna Gawlinski, DNSc, RN, FAAN Dana Rutledge, PhD, RN ABSTRACT Evidence-based practice models have been developed to help nurses move evidence into practice. Use of these models leads to an organized approach to evidence-based practice, prevents incomplete implementation, and can maximize use of nursing time and resources. Collaboration And Evidence Based Care Discussion
No one model of evidence-based practice is actors related to patient safety, quality, and F evidence-based practice (EBP) are driving changes in healthcare. Nurses are interested in how to move good evidence into practice to optimize patients’ outcomes; thus, nurses may benefit from understanding more about EBP models. These models have been developed to help nurses conceptualize moving evidence into practice. They can assist nurses in focusing efforts derived either from clinical problems or from “good ideas” toward actual implementation in a specific practice setting. Use of EBP models leads to systematic approaches to EBP, prevents incomplete implementation, promotes timely evaluation, and maximizes use of time and resources. This article describes a systematic process for organizations to use as a template for choosing an EBP nursing model. Strategies for involving staff nurses and clinical and administrative leaders are discussed. Finally, a summary of key EBP nursing models is presented. Creating Structures or Forums for Discussions The first step in selecting a model is to establish a structure or a forum in which presenta- present that meets the needs of all nursing environments. This article outlines a systematic process that can be used by organizations to select an evidence-based practice model that best meets the needs of their institution. Keywords: evidence-based practice models, evidence-based practice, models tions and discussions can occur about various EBP models, their advantages and disadvantages, and their applicability to organizational needs. Several possible strategies include: • use of an existing nursing research committee in which selection of an EBP model is added to annual goals and activities; • formation of an EBP council, with an initial task of selecting an EBP model; • appointment of a task force charged with selecting an EBP model; • use of an educational event to increase knowledge about EBP models while facilitating the selection of a model appropriate for the organization; and • use of a focus group process to select an EBP model consistent with the philosophy, vision, and mission of the organization.1 Anna Gawlinski is Director, Evidence-Based Practice, and Adjunct Professor, Ronald Reagan University of California, Los Angeles Medical Center & University of California, Los Angeles School of Nursing, 757 Westwood Plaza, Los Angeles, CA 90095 ([email protected]). Dana Rutledge is Professor, Department of Nursing, California State University Fullerton; and Nursing Research Facilitator, Saint Joseph Hospital, Irvine, California. 291 AACN1903_291-300 16/7/08 09:05 PM Page 292 G AW L I N S K I A N D R U T L E D G E AACN Advanced Critical Care Any of these strategies could help “set the stage” for an organization to choose an EBP model. For example, the authors used an existing nursing research committee/council to begin the process of selecting an EBP model in 2 different settings. In a third hospital, a multidisciplinary EBP council took on the task of selecting an EBP model. Collaboration And Evidence Based Care Discussion
Regardless of the structure or the forum used, a thoughtful and systematic process is helpful. Composition of the Committee or the Group The second step to identifying an EBP model is to carefully consider appropriate members of the committee or the group. Administrative and clinical leaders such as nurse managers, clinical nurse specialists, and nurse educators should be represented, as should interested staff nurses. Staff nurses who are clinical resources in their units, share an interest in improving patient care, or are curious about research are likely members. The educational level of the committee members should reflect that of nurses within the department or the institution and will most commonly include nurses with associate, bachelor’s, and master’s degrees. In addition, members should represent the various clinical units/departments or specialties within the institution. Involvement of persons with special expertise in research or EBP, such as a nurse researcher or faculty member from a local unit, hospital, or school of nursing, may be especially helpful. These persons may be internal or external to the organization and have valuable expertise in EBP nursing models. They can function as active members or as consultants. A librarian member may also be useful in retrieving needed publications to evaluate selected models. The evaluation process and the number of EBP models that are considered can influence the desirable number of committee members. For example, at one institution (a university academic hospital), the nursing research council selected 7 EBP nursing models for review and evaluation. Table 1 lists the models and shows the criteria used to evaluate them. These 7 models were chosen for evaluation either because they were commonly mentioned in publications about EBP nursing models or because they were identified by committee members. At another institution (a community hospital), the nursing research council selected 4 EBP nursing models to eval- uate on the basis of council members’ knowledge of the models’ utility and potential fit with the organization. Involvement of all committee members in the evaluation process is vital. Using a process where 2 or 3 persons volunteer to review and present 1 to 2 EBP nursing models can get all members involved. Staff nurses can be paired with administrative or clinical leaders in teams of 2 to 3 persons. All committee members can then participate in the process of evaluating models by attending presentations about each model and actively participating in discussions. By having small groups present each model, the workload is divided among group members. The more people involved in the process, the greater the need for coordination and oversight by the chairperson. Organizing the First Meeting Once the group has been selected, the next step is to organize the first meeting so that clear communication about the roles and responsibilities of team members can occur. The chairperson or the leader can survey the group members to determine the optimal date, time, and comfortable location for this meeting. Because of the nature of the work involved in selecting a model, 2 hours is an optimal duration for meetings. An agenda should accompany the meeting invitations and initially will include items such as discussions of the purpose and goals of the committee and the roles and responsibilities of committee members (Table 2)Collaboration And Evidence Based Care Discussion.
Providing a brief reading assignment that gives an overview of EBP models and should be completed before the first meeting is advisable. The chairperson can request committee members who are already knowledgeable about EBP models to highlight parts of the reading assignment at the first meeting to promote discussion. The chairperson should also collaborate with unit leaders to ensure that staff nurses have appropriate release time for meetings. Roles and Responsibilities of Committee or Members At the first meeting, roles and responsibilities of the members for reviewing, presenting, and evaluating each EBP model should be addressed. Assignments and due dates are determined to ensure steady progress. For example, a member can elect to work in a small group to review the literature on an EBP 292 AACN1903_291-300 16/7/08 09:05 PM Page 293 V O L U M E 1 9 • N U M B E R 3 • J U LY – S E P T E M B E R 2 0 0 8 SELECTING A MODEL FOR EBP CHANGES Table 1: Evaluation Criteria and Scoring for 7 Models of Evidence-Based Practice Changesa Evaluation Criteria for EBP Model Purpose of Project: Evaluation and selection of an EBP model for the Nursing Department of Ronald Reagan University of California, Los Angeles Medical Center. 1. Search, retrieve, and synthesize the current literature describing EBP models to help staff nurses use EBP concepts and apply them in clinical practice. 2. Recommend the adoption of a specific EBP model for use by UCLA nurses. Scoring system: 0 not present; 1 present/yes; 2 highly present/yes Criteria Models 1. Concepts and organization of model are clear and concise 2. Diagrammatic representation of the model allows quick assimilation of concepts and organizes the steps in the process of EBP changes 3. The model is comprehensive from beginning stages through implementation and evaluation of outcomes 4. The model is easy to use when concepts are applied to direct EBP changes and practice issues in clinical settings 5. The model is general and can be applied to various populations of patients, EBP projects, and department initiatives and programs 6. The model can be easily applied to typical practice issues as evidenced with practice scenario or in published literature Total Comments EBP Model: Strengths: Weaknesses: EBP Model: Strengths: Weaknesses: EBP Model: Strengths: Weaknesses: EBP Model: Strengths: Weaknesses: EBP Model: Strengths: Weaknesses: a Used with permission from the Evidence-Based Practice Program, Nursing Department at Ronald Reagan University of California, Los Angeles Medical Center, Los Angeles, California. 293 AACN1903_291-300 16/7/08 09:05 PM Page 294 G AW L I N S K I A N D R U T L E D G E AACN Advanced Critical Care Table 2: Example of Agenda Items for the First Evidence-Based Practice Committee or Group Meeting Welcome and introduce members Review agenda Discuss the goals of the committee Discuss roles and responsibilities of committee members Select models for evaluation Discuss the process for presenting and evaluating evidence-based practice models Make assignments and schedule Identify resources and forms Identify strategies to communicate ongoing committee work to the department Open discussion of other items Plan for next meeting model. Work teams should be assigned a presentation date to present details of the reviewed EBP model to committee members. Presentations of each EBP model may take 30 to 45 minutes and might include information on the history and development of the EBP model (who, what, when, where, and how) Collaboration And Evidence Based Care Discussion
, revision of the model over time, overall concepts in the EBP model, the process and flow of the EBP model, and publications describing how the model guided EBP changes in other facilities. Each presentation of an EBP model can be followed by 10 or 15 minutes for group members to raise questions and discuss specific aspects of the EBP model. After the presentation and discussion, group members could review an example of how the EBP model might be applied in a realistic practice scenario that requires consideration of a practice change (Table 3). Group members could then use the EBP model under discussion to address the practice issue. Depending on the group’s size, this work can be done in small groups, with each small group slated to report back to the larger group its opinion about how the model “worked.” It is recommended that groups break into smaller groups of 2 or 3 persons to “rate” the models’ applicability on the basis of predetermined criteria (Table 4). Criteria for evaluating the applicability of the EBP model should include clarity of the EBP model concepts and diagrammatic representation, applicability of the EBP model to clinical practice issues for diverse patient care situations in the institution, ease and user-friendliness of the EBP model, and the ability of the EBP model to provide direction for all phases of the EBP process. Table 1 shows an example of an evaluation tool that can be used by committee members when reviewing each EBP model. After the evaluation instrument is administered and scored, committee members can compare and contrast the ratings, strengths, and weaknesses for addressing the practice scenarios, and potential adoption by the institution for each model is reviewed. The use of a structured process provides members with little or no background in evaluating an EBP model to learn about EBP models and have greater participation and support in the evaluation process. The link of the EBP model to practice is clear when the practice scenario is used. Members increase their knowledge and skills in using EBP models for practice changes and become champions for the adoption of a model within the organization. Finally, the ongoing work of the committee should be communicated through forums such as mass e-mails, newsletters, posters, nursing grand rounds, and other continuing education programs. Such communication helps disseminate the process used in selecting a model for the organization, while inviting others to participate via comments and feedback. Summary of Selected EBP Nursing Models A number of EBP models have been developed; many appear very different from each other. Some of these models are more useful in some contexts than others, and each has advantages and disadvantages. The following steps or phases are common to most models: • Identification of a clinical problem or potential problem • Gathering of best evidence • Critical appraisal and evaluation of evidence; when appropriate, determination of a potential change in practice • Implementation of the practice change • Evaluation of practice change outcomes, both in terms of adherence to processes and planned outcomes (eg, clinical, fiscal, administrative) 294 AACN1903_291-300 16/7/08 09:05 PM Page 295 V O L U M E 1 9 • N U M B E R 3 • J U LY – S E P T E M B E R 2 0 0 8 SELECTING A MODEL FOR EBP CHANGES Table 3: Sample Practice Scenario for Evaluating Applicability of Models for EvidenceBased Practice Changesa Scenario for Application of Evidence-Based Practice Nursing Models Note: The following scenario includes selected literature on the subject for the purpose of providing a clinical practice issue for use when applying EBP models. The following does not include an extensive or integrated review of the literature on the subject. Clinical Issue Suctioning patients who have endotracheal and tracheal tubes is a frequent and important nursing intervention. These tubes interrupt the normal mucociliary system and can result in a patient’s inability to mobilize and expectorate secretions).13 Suctioning is an intervention that has beneficial effects such as removal of secretions, maintenance of airway patency, and promotion of optimal ventilation and oxygenation.13 It is common practice for nurses and other healthcare providers to instill 3 to 10 mL of sodium chloride in the endotracheal or tracheal tubes before suctioning.14 The action of sodium chloride is believed to loosen and thin secretions, stimulate a cough, and lubricate the suction catheter.13,15,16 Collaboration And Evidence Based Care Discussion
Research and Evidence-Based Literature Results of research on the benefits of sodium chloride instillation have been inconclusive.13,17–23 In fact, studies indicate that this practice may result in the following adverse outcomes: • • • • Interferes with the alveolar-capillary oxygen exchange, causing a decrease in oxygen saturation, Increases rate of respiration, Increases the risk of infection by dislodging significantly more bacterial colonies, and Increases intracranial pressure.13,19,21,22 Furthermore, patients can panic or feel as though they are drowning during routine instillation of sodium chloride via endotracheal or tracheal tubes.24 Research results indicate that mucus and sodium chloride solution are immiscible.13,17 Therefore, it is unlikely that instillation of sodium chloride loosens secretions and aids in the expectoration of airway secretions.13 The application of heat and humidification to the airway and the use of sodium chloride nebulizers are effective in thinning secretions and promoting airway clearance.13,23 Nursing Staff and EBP Process The nurses in your unit have recently heard a lecture presenting the lack of evidence supporting the routine use of instillation of sodium chloride before suctioning patients with endotracheal and tracheal tubes and the potential deleterious effects. They are questioning this practice and come to you as the unit manager or the clinical nurse specialist to help them with considering a change in this practice. Reflect on this EBP model to guide you through the steps to help your staff with this EBP change project. a Used with permission from the Evidence-Based Practice Program, Nursing Department, Ronald Reagan University of California, Los Angeles Medical Center, Los Angeles, California. Table 4: Criteria for Evaluation of Evidence-Based Practice Models to Meet Institutional Needs Concepts and organization of the model are clear and concise Diagrammatic representation of the model allows quick assimilation of concepts and organizes the steps in the process of EBP changes Model is comprehensive from beginning stages to implementation and evaluation of outcomes Model is easy to use when concepts are applied to direct EBP changes and practice issues in clinical settings Model is general and can be applied to various populations of patients, EBP projects, and department initiatives and programs Model can be easily applied to typical practice issues as evidenced with practice scenario or in the published literature Abbreviation: EBP, evidence-based practice. 295 AACN1903_291-300 16/7/08 09:05 PM Page 296 G AW L I N S K I A N D R U T L E D G E AACN Advanced Critical Care Table 5: Selected Evidence-Based Practice Nursing Models and Key Components Emphasis Stages/ phases Iowa Model3 Stetler’s Model2 Organizational process At individual nurse or organizational level 1 Trigger: Problem 1 Preparation or new knowledge 2 Validation 2 Organizational 3 Comparative priority? evaluation 3 Team formation 4 Decision making 4 Evidence gathered 5 Translation/ application 5 Research base critiqued and 6 Evaluation synthesized 6 Sufficient? 7 Pilot change 8 Decision? 9 Widespread implementation with continual monitoring of outcomes Rosswurm and Larrabee’s Model4 Johns Hopkins Nursing Model5 Organizational process Organizational process ACE Star Model of Knowledge Transformation6 Knowledge transformation 1 Assess need for change in practice 1 Practice question identified 1 Knowledge discovery 2 Link problem interventions and outcomes 2 Evidence gathered 2 Evidence summary 3 Synthesize best evidence 3 Translation: Plan, implement, evaluate, and communicate 3 Translation into practice recommendations 4 Design practice change 4 Integration into practice 5 Implement and evaluate change in practice 5 Evaluation 6 Integrate and maintain 10 Dissemination of results The following paragraphs describe several EBP models that are often considered for use in hospitals (Tables 5 and 6). These models were selected on the basis of the following criteria: (1) they commonly appear in nursing publications about EBP models; (2) published reports support their use to guide EBP changes in the clinical setting; (3) institutions (hospitals or schools of nursing) use the model; and (4) the models are intended to be used by nurses as they set out to find and use evidence to enhance patients’ or organizations’ outcomes. Table 5 describes selected EBP models that have specific steps or phases to guide the EBP process. Table 6 identifies key components of EBP models that do not have specific steps or phases but help describe and conceptualize the many variables and interactions that occur when making EBP practice changes. One of the oldest models that has recently been revised to include EBP outcomes is Stetler’s EBP model.2 This model is one of the few that does not focus entirely on formal changes led by nurses in organizational settings, suggesting use by individual nurses as well. Developed as a model for nurses within an East Coast hospital, Stetler’s model promotes use of both internal (eg, data from quality improvement, operational, or evaluation projects) and external (primary research evidence and consensus of national experts) evidence. Stetler’s model consists of 5 phases, ranging from searching for evidence about a clinical problem to formal and/or informal evaluations. Collaboration And Evidence Based Care Discussion
Decision making about whether a practice change should be made includes consideration of substantiating evidence, setting fit, feasibility, and current practice. Developed as a model to promote quality care, the Iowa model of EBP has been used in multiple academic and clinical settings.3 This model melds quality improvement with research utilization in an algorithm that nurses find intuitively understandable. Unique to the Iowa model is the concept of “triggers” of EBP. Evidence-based practice may be spurred by a clinical problem or by knowledge coming from 296 AACN1903_291-300 16/7/08 09:05 PM Page 297 V O L U M E 1 9 • N U M B E R 3 • J U LY – S E P T E M B E R 2 0 0 8 SELECTING A MODEL FOR EBP CHANGES Table 6: Select Evidence-Based Practice Frameworks ARCC Model7–9 PARIHS Framework10,11 Key focus Organization of department or unit Understanding key components of EBP Key concepts EBP mentor—an individual who has expert knowledge and skills in EBP and the passion to help others practice daily from an evidence base Evidence Major proposition The development of APNs and other nurses as EBP mentors facilitates an organizational culture change toward evidence-based care Practice changes are most likely when they are based upon robust evidence, conducted in a context “friendly” to change, and facilitated well Utility—practical implications Need to… Need to… • assess and organize culture and readiness for EBP • critically appraise evidence • identify strengths and major barriers to EBP implementation • implement ARCC strategies • develop and use EBP mentors • interactive EBP skill-building workshop Context Facilitation • thoroughly understand the practice arena before implementing a change • make a strategic plan for facilitation of any practice change— from development to implementation and evaluation • make EBP rounds and form journal clubs • implement EBP • improve patient, nurse, and system outcomes Abbreviations: ARCC, Advancing Research and Clinical Practice through Close Collaboration; EBP, evidence-based practice; PARIHS, Promoting Action on Research Implementation in Health Services. outside an organization. Either of these triggers can set an EBP project into motion. Thereafter, the model delineates 3 key decision points during the process of making a practice change: (1) Is there an institutional reason to focus on this problem or use this knowledge? (2) Is there a sufficient research base? (3) Is the change appropriate for adoption in practice? At 2 of these points, users must focus on the realities within an organizational context; the third point infers the possibility that evidence is not sufficient and thus that a research study may be needed or other evidence sought. Rosswurm and Larrabee4 developed a 6-step model for change in EBP that aims for integration of EBP into a care delivery system. The initial need for change is determined by comparing internal data such as quality indicators with data from outside the organization. When possible, this problem is linked to standard interventions and outcomes. Research and contextual evidence are sought to solve the problem and combined with clinical judgment. With sufficient evidence, a practice protocol is developed and a pilot test done to determine effects on outcomes. With widespread implementation, both processes (eg, staff adherence to the change) and clinical outcomes are evaluated. The practice change is maintained by using theoretically derived diffusion strategies. The Johns Hopkins Nursing EBP model was developed in collaboration with the Johns Hopkins Hospital and the Johns Hopkins University School of Nursing.5 To ensure that current research findings were incorporated into patient care, nursing administrative leaders from Johns Hopkins Hospital developed a model for the department of nursing. The resulting model addressed the following 3 297 AACN1903_291-300 16/7/08 09:05 PM Page 298 G AW L I N S K I A N D R U T L E D G E AACN Advanced Critical Care domains of professional nursing: nursing practice, education, and research. The model incorporates use of available evidence as a core component for decision making within these domains. Guidelines for the model reflect the “PET” process, an acronym that stands for practice question, evidence, and translation. First, a team identifies an important practice question. The team gathers evidence by reviewing literature, rates the evidence, and makes recommendations for changes in processes of care or systems. The last phase is the translation in which a plan of action is developed and implemented and outcomes are evaluated and communicated.5 The ACE Star Model of Knowledge Transformation aims to promote EBP by depicting knowledge types (from research to integrative reviews to translation) as necessary precursors to practice integration.6 This model does not discuss use of nonresearch evidence. The 5 major stages of knowledge transformation are (1) knowledge discovery, (2) evidence summary, (3) translation into practice recommendations, (4) integration into practice, and (5) evaluation. The goal of the process is knowledge transformation, defined as “the conversion of research findings from primary research results, through a series of stages and forms, to impact on health outcomes by way of [evidence-based] care.”6 Another EBP model that is considered a “mentorship” model is the Advancing Research and Clinical Practice through Close Collaboration model. This EBP model resembles an organizational plan for a department of EBP. The model focuses on establishing relationships across systems to bring experienced researchers together with clinicians to integrate research and clinical practice more fully.7 Originally an organizational model for linkages between a college of nursing and a medical center, the model relies heavily on EBP mentors, ideally advanced practice nurses, with in-depth knowledge of EBP and expert clinical and group facilitation skills.7–9 This model may be most useful in academic settings with formal linkages between nursing education and practice in which APNs are abundant. Out of the British system comes the Promoting Action on Research Implementation in Health Services framework,10,11 which is “useful as a heuristic device to help make sense of the many variables and interactions that take place in practice.”12(pS1) This intuitive model aids in understanding the key components of EBP: evidence, context, and facilitation. The model aims to represent the complexity of making practice changes on the basis of evidence. The key proposition in the model is that “the nature of the evidence, the quality of the context, and the type of facilitation all impact simultaneously on whether implementation is successful.”11(p178) Further understanding of the relationships among evidence, context, and facilitation is needed to maximize EBP. This model, though very useful as a theoretical explanation, has not been documented as useful in driving projects within organizations. Selection of EBP Model for the Institution After evaluation of each of the EBP models, committee members should be able to narrow the selection of these models to 1 or 2 models. This can be done by selecting the top 2 models with the highest scores on the evaluation tool and by discussions that facilitate group consensus. If 2 models score similarly on the evaluation tool, having members discuss general advantages and disadvantages of each of the models can help delineate the model that “fits” the needs of the organization best. For example, the group members might discuss advantages and disadvantages of the models reviewed and make the final selection on the basis of (1) how easy the EBP model was to understand and whether it would guide users in the EBP process; (2) appropriate direction by the model for the conduct of research when evidence is insufficient to support a practice change; (3) the flow of steps in the model is similar to the flow of practice algorithms for staff; and (4) decision points in the EBP model would provide users with opportunities for thoughtful reflection and decision making. To maximize leadership buy-in, nurse managers, administrators, and clinical leaders who are not part of the selection committee should also be included in the evaluation and selection process. This can be accomplished by having members of the nursing research committee attend leadership meetings to present either the final model or the final 2 models determined by the selection committee. Leadership members can then participate in the exercise of evaluating and scoring the final model(s) by using the practice scenario. The management group can then discuss the results, 298 AACN1903_291-300 16/7/08 09:05 PM Page 299 V O L U M E 1 9 • N U M B E R 3 • J U LY – S E P T E M B E R 2 0 0 8 SELECTING A MODEL FOR EBP CHANGES advantages, and disadvantages, and make final recommendation for adoption. Including broader nursing leadership representation in the selection of an EBP model would build consensus and promote support of the adopted model. If the initial committee is having trouble making a decision, leadership input can help break a tie or may result in new insights as to why one model might fit better than another. Dissemination and Integration of the Selected Model Once the model is chosen, the committee can brainstorm strategies to promote its dissemination and use. Educational sessions that are planned should use active participation of learners to enable participants to increase their knowledge and skills in using the model to answer clinically important questions that require evidence-based solutions. Several strategies can be used for dissemination and integration of the selected model: • Incorporating a class about EBP and the selected model into the new graduate orientation or residency program. This ensures that each new employee has basic knowledge about the use of the selected model. • Add content about use of the EBP model in preceptor development programs. Collaboration And Evidence Based Care Discussion
Preceptors are often clinical leaders in their respective units. Enhancing their knowledge and skills about EBP models can increase the likelihood that preceptors will serve as agents of change and champions of EBP within their clinical areas. • Incorporate education and skill building on use of the selected EBP model into the annual skills laboratories or competency forums. This strategy ensures wider dissemination of the selected model and aids in establishing baseline knowledge and skills for all nurses throughout the organization. • Conduct nursing grand rounds on the selected model, with examples of use of the model in clinical practice. Grand rounds can provide a forum for more in-depth knowledge and skill building with respect to use of the model. Examples of how the model can be used to answer important clinical practice questions can also be presented and discussed. Feedback can be obtained from the grand rounds participants about the clarity and feasibility of using the model for the EBP process. Ideas can be elicited from the • • • • • participants about strategies to overcome challenges to using the model. Provide EBP programs for the nursing leadership group. The program should introduce this group to more extensive concepts of the model, involve them in several examples of how to use the model for both administrative and clinical changes, and discuss their role in increasing use of the model in their respective areas. The infrastructures available to facilitate use of the model should also be discussed. Implement special “train-the-trainer” EBP development programs. Content about various innovative methods to teach others about the model should be included, along with a general discussion of the structure, concepts, and processes of the model. Include content in institution-sponsored research and EBP conferences by selecting programs that increase participants’ knowledge and skill building relative to the use of the model for EBP practice changes. Integrate the selected EBP model into the curriculum of any existing EBP immersion programs, such as an EBP internship or fellowship programs. Encourage members of the nursing research committee/council to brainstorm additional ideas that work best in their respective units, institution, and nursing culture. Members can examine what educational programs and forums already exist that could be used to disseminate and integrate the model in the organization. Summary Using a model for EBP change will assist nursing departments to better focus their limited fiscal and personnel resources on critical EBP activities. This article described structures and processes that institutions could use to facilitate choosing a model for EBP change that fits their practice setting and guides efforts in making EBP changes. References 299 1. Rempher KJ. Putting theory into practice: six steps to success. Am Nurs Today. 2006;11:41–42. 2. Stetler CB. Updating the Stetler model of research utilization to facilitate evidence-based practice. Nurs Outlook. 2001;49(6):272–279. 3. Titler MG, Kleiber C, SteelmanVJ, et al. The Iowa model of evidence-based practice to promote quality care. Crit Care Nurs Clin North Am. 2001;13(4):497–509. 4. Rosswurm MA, Larrabee JH. A model for change to evidence-based practice. IMAGE. 1999;31(4):317–322. AACN1903_291-300 16/7/08 09:05 PM Page 300 G AW L I N S K I A N D R U T L E D G E AACN Advanced Critical Care 5. Newhouse R, Dearholt S, Poe S, Pugh LC, White KM. Evidence-based practice: a practical approach to implementation. J Nurs Adm. 2005;35:35–40. 6. Academic Center for Evidence-Based Practice, The University of Texas Health Science Center at San Antonio. The ACE: learn about EBP page. http://www.acestar .uthscsa.edu/Learn_model.htm. Accessed November 30, 2007. 7. Ciliska D, DiCenso A, Melnyk BM, Stetler CB. Using models and strategies for evidence-based practice. In: Melnyk BM, Fineout-Overhold E, eds. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. Philadelphia: Lippincott Williams & Wilkins; 2005:185–219. 8. Fineout-Overhold E, Melnyk BM, Schultz A. Transforming health care from the inside out: advancing evidencebased practice in the 21st century. J Prof Nurs. 2005;21 (6):335–344. 9. Melnyk BM, Fineout-Overhold E, Stone P, Ackerman M. Evidence-based practice: the past, the present, and recommendations for the millennium. Pediatr Nurs. 2000; 26:77–80. 10. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence-based practice: a conceptual framework. Qual Health Care. 1998;7:149–158. 11. Rycroft-Malone J, Kitson A, Harvey G, et al. Ingredients for change: revisiting a conceptual framework. Qual Saf Health Care. 2002;11:174–180. 12. Kitson A. What influences the use of research in clinical practice? Nurs Res. 2007;56(4)(suppl):S1–S3. 13. Taylor-Piliae RE. Establishing evidence-based practice: issues and implications in critical care nursing. Intensive Crit Care Nurs. 1998;14(1):30–37. 14. Ackerman MH. The use of bolus normal saline instillations in artificial airways: is it useful or necessary. Heart Lung. 1985;14(5):505–506. 15. Raymond SJ. Normal saline instillation before suctioning: helpful or harmful? A review of the literature. Am J Crit Care. 1995;4(4):267–271. 16. Wood CJ. Endotracheal suctioning: a literature review. Intensive Crit Care Nurs. 1998;14(3):124–136. 17. Demers RS, Saklad M. Minimizing the harmful effects of mechanical aspiration. Heart Lung. 1973;2(4): 542–545. 18. Hanley MV, Rudd T, Butter J. What happens to intratracheal saline instillations? Am Rev Respir Dis. 1978;117 (4)(suppl):124–124. 19. Bostick J, Wendelgass ST. Normal saline instillation as part of the suctioning procedure: effects on PaO2 and amount of secretions. Heart Lung. 1987;16(5): 532–537. 20. Gray JE, MacIntyre NR, Kronenberger WG. The effects of bolus normal-saline instillation in conjunction with endotracheal suctioning. Respir Care. 1990;35(8): 785–790. 21. Ackerman MH. The effect of saline lavage prior to suctioning. Am J Crit Care. 1993;2(4):326–330. 22. Hagler DA, Traver GA. Endotracheal saline and suction catheters: sources of lower airway contamination. Am J Crit Care. 1994;3(6):444–447. 23. Williams R, Rankin N, Smith T, Galler D, Seakins P. Relationship between the humidity and temperature of inspired gas and the function of the airway mucosa. Crit Care Med. 1996;24(11):1920–1929. 24. Jablonski RA. If ventilator patients could talk. RN. 1995; 58(2):32–34. 300 Remote Collaboration and Evidence-Based Care Scoring Guide CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED Propose your evidencebased care plan to improve the safety and outcomes for the Vila Health patient with a discussion of new content for the care plan. Does not propose an evidence-based care plan to improve the safety and outcomes for the Vila Health patient. Describes an evidence-based care plan, but the relevance to the Vila Health patient or how the plan would improve outcomes is absent or unclear. Proposes your own evidencebased care plan to improve the safety and outcomes for the Vila Health patient with a discussion of new content for the care plan. Proposes your evidence-based care plan to improve the safety and outcomes for the Vila Health patient with new content added. Notes areas in which further information or data could have been useful in developing the plan. Explain the ways in which you used the specific evidencebased practice model to help develop the care plan, identifying what interventions would be necessary. This requires a particular evidencebased model, such as the Johns Hopkins, Iowa, Stetler, or other. Does not explain the ways in which you used the specific evidencebased practice model to help develop the care plan, identifying what interventions would be necessary. Identifies an EBP model and lists the ways in which you use the specific evidence-based practice model to help develop the care plan. Explains the ways in which you used the specific evidence-based practice model to help develop your care plan, identifying what interventions would be necessary. Uses a particular evidence-based model, such as the Johns Hopkins, Iowa, Stetler, or other. Explains the ways in which you used the specific evidencebased practice model to help develop your care plan. Notes ideas for how to evaluate the positive benefits to patient outcomes. Reflect on which evidence you collected that was most relevant and useful when making decisions regarding the care plan. Does not reflect on which evidence you collected that was most relevant and useful when making decisions regarding the care plan. Lists which evidence you collected that was most relevant and useful when making decisions regarding the care plan. Reflects on which evidence you collected that was most relevant and useful when making decisions regarding the care plan. Reflects on which evidence you collected that was most relevant and useful when making decisions regarding the care plan. Discusses the rationale or criteria that was used to determine relevance and usefulness. Identify benefits and propose strategies to mitigate the challenges of interdisciplinary collaboration to plan care within the context of a remote team. Does not identify benefits or propose strategies to mitigate the challenges of interdisciplinary collaboration to plan care within the context of a remote team. Identifies benefits or proposes strategies to mitigate the challenges, but not both, of interdisciplinary collaboration to plan care within the context of a remote team. Identifies benefits and proposes strategies to mitigate the challenges of interdisciplinary collaboration to plan care within the context of a remote team. Collaboration And Evidence Based Care Discussion
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Identifies benefits and proposes strategies to mitigate the challenges of interdisciplinary collaboration to plan care within the context of a remote team. Discusses how interdisciplinary collaboration could be better leveraged to improve outcomes in future care situations. Communicate via video with clear sound and light, and include a narrative of video content. Does not communicate professionally in a well-organized presentation and does not include a narrative of video content. Does not communicate via video or video is difficult to hear and see, but does include a narrative of video content. Communicates via video with clear sound and light and does include a narrative of video content. Communicates via video with clear sound and light. Content delivery is focused, smooth, and well-rehearsed. Includes a narrative of the video. Video presentation is between 5 to 10 minutes. Provide a full reference list that is relevant and evidence-based (published within five years), exhibiting nearly flawless adherence to APA format. Does not provide a reference list of relevant and/or evidence-based sources (published within five years). Provides reference list that is not relevant and/or evidence-based with several APA errors. Provides a reference list that is relevant and evidence-based (published within five years) sources, exhibiting nearly flawless adherence to APA format. The reference list is from relevant and evidence-based (published within five years) sources, exhibiting flawless adherence to APA format. Vila Health ® Activity Remote Collaboration and Evidence-Based Care Introduction The Patient Presents Collaboration Begins Consulting With the Pediatrician The Care Plan Continues Respiratory Therapist Consult on Skype Conclusion Introduction Evidence-based care can be a challenge in any medical situation, but particular challenges present themselves when care is being provided remotely. In order to provide quality care to patients who live in rural settings or have difficulty with transportation to a care site, health care professionals must sometimes collaborate with other professionals in different ZIP codes or even time zones. In this activity, you will observe how health care professionals collaborate remotely and virtually to provide care for a patient in Valley City, North Dakota. The Patient Presents Dr. Erica Copeland and Virginia Anderson, a pediatric nurse, discuss Caitlynn, who came into the ER last night and has now been admitted to the pediatric unit. Dr. Copeland starts the conversation. Dr. Copeland: Nurse, can you give me an update on Caitlynn? I know she’s two years old and she’s been admitted for pneumonia. Does she have any history of breathing problems? Virginia Anderson: Yes, this is her second admission for pneumonia in the last six months. She had a meconium ileus at birth. Dr. Copeland: All right. Is she presenting with any other symptoms? Virginia Anderson: She has decreased breath sounds at the right bases and rhonchi scattered in the upper lobes. Respirations are 32 and shallow with a temp of 101. Dr. Copeland: What have we done for her so far? Virginia Anderson: The respiratory therapist administered nebulized aerosol and chest physiotherapy. After the aerosol she had thick secretions. Dr. Copeland: I see her weight is 20.7 pounds, and there’s been some decreased subcutaneous tissue observed in her extremities? Virginia Anderson: Correct. I noticed this too, so she might have some malabsorption of nutrients. Dr. Copeland: Have we done a sweat chloride test yet? Virginia Anderson: Yes, and the results were 65 milliequivalents per liter. Also, the mother reports that when she kisses her, she tastes salty. Dr. Copeland: All right. Well, I think it’s fair to say we might be dealing with cystic fibrosis here. Let’s get her started on an IV with piperacillin, and keep an eye on her temperature. Collaboration Begins Later, the diagnosis is confirmed: Caitlynn has cystic fibrosis. Dr. Copeland, Virginia Anderson, and Rebecca Helgo, the hospital’s respiratory therapist have a short consult, where they realize that Caitlynn’s care will not be easy. Dr. Copeland starts the conversation. Dr. Copeland: Let’s talk about Caitlynn Bergan. Her mother, uh, [checks notes] Janice, has been informed of her diagnosis. I didn’t realize this when she first came in, but she doesn’t live in Valley City; she’s in McHenry. Rebecca Helgo: That’s a tough drive during winter. They’re over an hour away, aren’t they? Dr. Copeland: That’s right. It was a toss-up between coming here or going to Jamestown, but I guess the father — Doug — thought Valley City was the better choice. Anyway, I’ve put her on Pancrease enzymes and we’ll be recommending a high-protein, extra-calorie diet along with the fat-soluble vitamins — A, D, E, and K. I’ll update her pediatrician on her condition, and order dornase alfa. Let’s see how she does with the breathing treatments. How are those going? Rebecca Helgo: Quite well, actually. She’s too young to get her to do the huff breaths, but we’re keeping the secretions thin and manageable with the aerosol treatments. I am concerned about her day-to-day treatment, though. She’ll be back here with pneumonia if the parents can’t stay on top of that. She’s at risk for impaired gas exchange and respiratory distress, which will cause her anxiety and more distress, and that’s not going to help her stay well. Dr. Copeland: How well do you think the parents will be able to handle the treatment? Virginia Anderson: That might get tricky. I gather that the mother and father are still married but separated. We’ll need to make sure that at least one of them gets the education they need. But they both work, and trips here aren’t the easiest choice. We should get a social services consult to coordinate services and identify some assistance for the family in McHenry. Rebecca Helgo: I can do some education here, and then do a Skype consult with one or both of them once she’s been discharged and is back home. Dr. Copeland: It sounded like both parents work long hours. Are you going to be able to schedule times that work? Rebecca Helgo: I may have to do some after-hours appointments. We’ll have to sort that out. Virginia Anderson: She’s had one bowel obstruction already, so I think we need to help them monitor for DIOS too. Does the pediatrician’s office have a telemedicine relationship with us? That might be helpful in preventing unnecessary trips here. Dr. Copeland: Let’s find out a bit more and see what our options are. Consulting With the Pediatrician Later that day, Dr. Copeland and Virginia Anderson talk to Dr. Benjamin, Caitlynn’s pediatrician, about how his office can coordinate with the hospital on Caitlynn’s care. Dr. Copeland greets Dr. Benjamin. Dr. Copeland: Hello, Dr. Benjamin. I’m sorry to be meeting under such circumstances, but I hope we can work with you to help the Bergans handle Caitlynn’s care. On the line with me is Virginia Anderson, the nurse assigned to Caitlynn while she’s here. Dr. Benjamin: Hello to both of you. Yes, it’s unfortunate. This is the first case I’ve seen among my own patients. Dr. Copeland: Are you familiar with the CF protocol? Dr. Benjamin: I am, but I’d love to get any more details that relate to Caitlynn. She’s done with most of her immunizations, but she’s still needs her HAV and influenza, of course. I’m also not sure where to order some of the pancreatic enzymes and medications you listed. Virginia Anderson: We can help with all that. Do you have telemedicine access to Valley City? Dr. Benjamin: No, but we do have it with Cooperstown Medical Center. We kind of have to in a town of less than 100 people. Dr. Copeland: We may be able to use Skype on a more informal basis for consults between us, but it might be good to get connected with Valley City on your telemedicine equipment. If the parents bring Caitlynn to you with symptoms, and you’re not sure whether the hourlong trip is necessary, we can do a telemedicine appointment and make sure. Dr. Benjamin: All right. It sounds like we might see them often initially, and I understand that bowel obstructions and pneumonia are two possible complications. Collaboration And Evidence Based Care Discussion
We can handle some of those issues here, but assuming they have trouble during working hours, I assume we can reach you by phone? Dr. Copeland: You or your staff can send me a text. If we need to talk further we can set up a call, but if not, text is the quickest way to get my attention, and the easiest way for me to respond between things. Virginia Anderson: And I’m available via text as well if you’re having trouble reaching Dr. Copeland or if it’s a question I can field. The Care Plan Continues To address some of the questions that came up during the consult, Virginia meets with Madeline Becker, the social worker at the clinic in McHenry. Virginia starts the conversation. Virginia Anderson: Hi, Madeline, this is Virginia Anderson at Valley City Regional Hospital. I’m on the line with Marta Simmons, our social worker here at the hospital. Madeline Becker: Hi, both of you. Marta Simmons: Madeline, we’re calling because Virginia is working on a care plan for a child from McHenry, a Caitlynn Bergan. She’s here after a bout of pneumonia and she’s been diagnosed with cystic fibrosis. We wanted to talk to you about resources there for some of the issues the Bergans are going to be dealing with. Madeline Becker: Of course. I got the documentation you emailed earlier. Fortunately, the Bergans are both employed and have good insurance through Doug’s new job. But as you may have heard, he was unemployed for some time, so money is tighter than it might seem. Virginia Anderson: We’ve talked to Janice and she isn’t sure what her insurance covers as related to the breathing and other treatments Caitlynn is likely to need. Madeline Becker: I can do some initial work on that. I’ll need a release from Janice to get detailed information, but I should be able to get general coverage information. What other resources might they need? McHenry is pretty small, as I’m sure you’re aware. Marta Simmons: The main issue is going to be the stress of caring for a child with a chronic illness. Even a group that helps members deal with grief would be helpful. Children with CF live much longer than they used to, but it’s still a difficult condition. Madeline Becker: There isn’t a group like that here, but there is one in Sheyenne. I mean, it’s more for parents in grief already, parents who have lost a child, but it’s a sizable group, relatively speaking. I’m sure there will be some parents who understand what it’s like to have a child with a difficult condition. Virginia Anderson: All right, that helps. Now, we’re going to provide as much education as we can before Janice takes Caitlynn home, but what kind of resources are there in McHenry? If she doesn’t have home Internet access, does the library offer it? Is there a library? Madeline Becker: No, the closest library is in Cooperstown. Marta Simmons: Well, we’ll talk to the Bergans’ pediatrician and see if they might be able to help if they need materials and can’t get them easily at home. This is progressive and lifelong, and they’re going to need some support as they learn to deal with it. Respiratory Therapist Consult on Skype A few days after Janice and Caitlynn go back to McHenry, Janice calls to talk to someone about whether she’s doing Caitlynn’s chest physiotherapy correctly. Virginia and Rebecca, the respiratory therapist, call her back on Skype to answer her questions. Virginia Anderson starts the conversation. Virginia Anderson: Hi, Janice, thanks for contacting us! We’re getting back to you about Caitlynn. With me on the line is Rebecca Helgo, the respiratory therapist who helped you out when you were here. Rebecca Helgo: Hi, Janice. Janice: [sounding stressed] Hi. Virginia Anderson: Janice, how is it going with Caitlynn? Janice: Well, that’s why I called, actually. Not so good. I mean, not bad, but I guess I’m not remembering everything you told me when we practiced the physiotherapy, the chest physiotherapy. Virginia Anderson: That’s okay, Janice. I know this feels overwhelming. Caitlynn’s condition is an extensive one, and we’re here to help you manage it. We’ll continue to be here as you’re figuring this out, okay? Rebecca Helgo: That’s right, Janice. I know you’ll get the hang of it, but in the meantime there’s a lot to learn. So you had some questions about the chest physiotherapy? What’s going on? Janice: Okay, if you can see on the camera, Caitlynn has these red marks on her ribs here. Is that a symptom of something? Rebecca Helgo: Can you get the camera just a bit closer? Janice: How’s that? Rebecca Helgo: Okay, very good. Yes, those look like marks from the percussion. Are those over her last two ribs? Janice: I think so. Rebecca Helgo: That’s one thing you’ll have to remember: You don’t want to do the percussion on her last two ribs on either side, her backbone, or her breastbone. And when you do it anywhere else, you don’t want to leave red marks. So if you see those, that’s a hint that you’re doing the percussion just a bit too hard. Virginia Anderson: Don’t worry, you haven’t hurt her that I can see. Plus, you’re obviously really staying on top of things and you’re following the recommended treatment procedures for Caitlynn, and I really want to praise you for that. So, is she acting like that area is hurting her? Or can you tell? Janice: No, it doesn’t seem like it’s hurting her at all. Rebecca Helgo: She should be fine, then. Virginia Anderson: And remember, Janice, if you continue to have trouble with this, we’ve got other options. There’s a vest that vibrates the child if percussion isn’t getting the job done. And you won’t have to do exactly this forever. As she gets older and can learn how to do huff coughs, you’ll be doing less work and she’ll be doing more. Janice: Okay. Thank you, that makes me feel better. I couldn’t get hold of my pediatrician and I was just getting worried. Rebecca Helgo: Good, that’s what we’re here for. Virginia Anderson: Janice, should we review the signs and symptoms of respiratory distress? We’re happy to go over anything you need to feel more confident about monitoring Caitlynn. Janice: I think I remember those. I feel like I check for them every hour. Rebecca Helgo: [chuckles] That’s understandable. Well, remember to check with Dr. Benjamin or me or Virginia if you need to. Conclusion As you saw in this activity, coordinating care can be a challenge when the patient lives far from her provider or when multiple providers are distant from each other. Many technologies may be necessary in order to provide quality evidence-based care to patients when care teams and patients are not in the same location. Nurses and other health care professionals must find creative solutions when problems arise, so that care planning for remote patients is just as comprehensive and outcome-based as that for patients nearby or on site. Reflection Questions As you work on your assignment, consider these questions: How was remote collaboration used to improve the quality and safety of the care being provided in the scenario? This question has not been answered yet. In what ways was evidence-based practice being effectively applied to help the patient in the scenario? Were there opportunities for improvement? If so, what were they? This question has not been answered yet. Collaboration And Evidence Based Care Discussion