Developing A Culture Of Evidence-Based Practice

As your EBP skills grow, you may be called upon to share your expertise with others. While EBP practice is often conducted with unique outcomes in mind, EBP practitioners who share their results can both add to the general body of knowledge and serve as an advocate for the application of EBP.

In this Discussion, you will explore strategies for disseminating EBP within your organization, community, or industry.

To Prepare:

  • Review the Resources and reflect on the various strategies presented throughout the course that may be helpful in disseminating effective and widely cited EBP.
    • This may include unit-level or organizational-level presentations, poster presentations, and podium presentations at organizational, local, regional, state, and national levels, as well as publication in peer-reviewed journals.
  • Reflect on which type of dissemination strategy you might use to communicate EBP.

Post at least two dissemination strategies you would be most inclined to use and explain why. Explain which dissemination strategies you would be least inclined to use and explain why. Identify at least two barriers you might encounter when using the dissemination strategies you are most inclined to use. Be specific and provide examples. Explain how you might overcome the barriers you identified.

Sustaining Evidence-Based Practice Through Organizational Policies and an Innovative Model

The team adopts the Advancing Research and Clinical Practice Through Close Collaboration model.

This is the 12th and last article in a series from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When it’s delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved. The complete EBP series is available as a collection on our Web site; go to www.ajnonline.com and click on Collections.

In July’s evidence-based prac-tice (EBP) article, Rebecca R., Carlos A., and Chen M. eval- uated the outcomes of their rapid response team (RRT) implemen- tation project. Their findings in- dicated that a significant decrease in one outcome, code rates outside the ICU, had occurred after im- plementation of the RRT. This promising finding, together with many other considerations—such as organizational readiness; clini- cian willingness; and a judicious weighing of all the costs, benefits, and outcomes—encouraged the EBP team to continue with plans to roll out the RRT protocol throughout the entire hospital system. They also began to work on presentations and publications about the project so that others could learn from their experience and implement similar interven- tions to improve patient outcomes.

USING EVIDENCE TO INFORM ORGANIZATIONAL POLICY Because Rebecca, Carlos, and Chen are concerned about whether the implementation of an RRT can be sustained over time in their hospi- tal, they want to take the neces- sary steps to create a hospital- wide

RRT policy. Therefore, they make an appointment with their hospi- tal’s director of policies and pro- cedures, Maria P., to share the outcomes data they’ve gathered from their project and to discuss the project’s success so far. Maria is impressed by the rigor of the team’s sequential EBP process and the systematic way in which they’ve gathered the outcomes data. She reminds them that the

measurement of outcomes (inter- nal evidence) plus rigorous re- search (external evidence) result in the best evidence-based orga- nizational policies to guide the high est quality of care in health care institutions.

Maria volunteers to assist the team in writing a new evidence- based policy to support having an RRT in their hospital. She suggests

that each recommendation in the policy be supported by evidence. Maria explains that once the pol- icy is written, it needs to be ap- proved by the hospital-wide policy committee, representing all of the health disciplines. Maria empha- sizes that transdisciplinary health care professionals and administra – tors should routinely be involved when planning and implementing evidenced-based organizational

policies. She also reminds the EBP team that translating evidence and evidence-based organizational pol- icies into sustainable routine clin- ical practices remains a major challenge for health care systems.

The new RRT policy written by Rebecca, Carlos, and Chen with Maria’s help is approved by the hospital-wide policy committee within three months. Now the

By Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP,

FAAN, Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN, Lynn Gallagher-

Ford, MSN, RN, NE-BC, and Susan B. Stillwell, DNP, RN, CNE, ANEF

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It only takes one passionate, committed

person to spearhead a team vision to

improve care for patients and their families.

 

 

challenge for the team is to work with clinicians across the hospital system to implement it. The EBP team schedules a series of presen- tations throughout the hospital to introduce the new RRT policy. They rotate the days and times of this in-service to capture as many direct care clinicians as possible. To ensure that all clinicians are educated on the new policy, a da- tabase is created to track in-ser- vice attendees, and each hos pital unit is asked to appoint a volun- teer to deliver the presentation to any clinicians who missed it. Post- ers are created and buttons de- signed as visual triggers to remind staff to implement the new policy.

Throughout this process, the EBP team learned that dissemi-

nation of evidence alone doesn’t typ ically lead clinicians to make a sustainable change to EBP, and they were impressed by how im- portant it was to have unit-based champions reinforce the new pol- icy.1 They also learned that it’s critical to have an organizational culture that supports EBP (such as evidence-based decision making in tegrated into performance ex- pectations, up-to-date resources and tools, ongoing EBP knowledge and skills-building workshops, and EBP mentors at the point of care) in order for clinicians to con- sistently deliver evidence-based care.2

Since the process they followed worked so well, the team believes that their hospital needs to adopt

a model to guide and reinforce the creation of a culture to sus- tain the EBP approach they had initiated through this project. They review several EBP process and system integration models and decide to adopt the Advanc- ing Research and Clinical Prac- tice Through Close Collaboration (ARCC) model because its key strategy to sustain evidence-based care is the presence of an EBP mentor (a clinician with advanced knowledge of EBP, mentorship, and individual as well as organi- zational change). With Carlos’s success as an expert EBP mentor, and the mentorship model work- ing so well, they believe that de- veloping a cadre of EBP mentors system-wide is key to the ongoing

58 AJN ▼ September 2011 ▼ Vol. 111, No. 9 ajnonline.com

Potential Strengths

Philosophy of EBP (paradigm is system-wide)

Presence of EBP mentors and champions Administrative support

Clinicians’ beliefs about the value of EBP and ability to implement the EBP processa

Identification of strengths and major

barriers to EBP implementation

 

EBP implementationa, b

 

 

Decreased hospital costs

Potential Barriers

Lack of EBP mentors and champions

Inadequate EBP knowledge and skills

Lack of EBP valuing

Implementation of ARCC strategies

Interactive EBP skills building

EBP rounds and journal clubs

 

Improved patient

outcomes

Nurse/clinician satisfaction Cohesion Intent to leave

Turnover

 

Development and use of EBP

mentors

Assessment of organizational

culture and readiness for EBPa

Figure 1. The ARCC Model for System-Wide Implementation and Sustainability of EBP ARCC = Advancing Research and Clinical Practice Through Close Collaboration; EBP = evidence-based practice. a Scale developed. b Based on the EBP paradigm and using the EBP process.

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that this model be adopted, not only for the nursing department, but for all disciplines throughout the organization.

THE EBP JOURNEY HAS JUST BEGUN This series presented a case in- volving a hypothetical medical– surgical nurse and her colleagues to illustrate how EBP can be suc- cessfully implemented to improve key patient outcomes. It’s impor- tant that the process start with an ongoing spirit of inquiry, and that nurses always question the

evidence behind the care we pro- vide and never settle for the sta- tus quo. Never forget that it only takes one passionate, committed person to spearhead a team vi- sion to improve care for patients and their families. It also takes persistence through the “charac- ter builders” that are sure to appear as the vision comes to fruition.

Although the EBP team has successfully completed their RRT implementation project and its incorporation as a hospital-wide policy, their EBP journey has just be gun. In fact, only days after the project’s completion, Rebecca asked Carlos another great PICOT question: “In critically ill patients, how does early ambulation com- pared with delayed ambulation affect ventilator-associated pneu- monia in the ICU?” Carlos looked at her and replied, as a great men – tor does, “I will help you search for the evidence and we will find

and organizational culture change. These individuals, whether expert system-wide mentors, advanced practice mentors, or peer mentors, are focused on helping point-of- care clinicians to use and sustain EBP and to conduct EBP imple- mentation, quality improvement, and outcomes management proj- ects. When clinicians work with EBP mentors, their beliefs about the value of EBP and their ability to implement it increase, and this is followed by a greater achieve- ment of evidence-based care.4

The ARCC model contends that greater implementation of EBP results in higher job satisfaction, lower turnover rate, and better patient outcomes. A series of studies now support the empiri- cal relationships in the ARCC model.4-8

The ARCC model has been and continues to be implemented in hospitals and health care sys- tems across the country with ex- cellent results in quality of care and patient outcomes. Valid and reli- able instruments, such as the EBP Beliefs and EBP Implementation scales,6 are used to measure key constructs in the model and, to- gether with organizational culture and readiness for EBP, help to de- termine the model’s effectiveness.6

The EBP team discusses how all the elements of the ARCC model are an excellent fit for their organization. They decide to make a recommendation to the Shared Governance Steering Committee

implementation and sustainabil- ity of EBP in their organization.

SUSTAINING AN EBP CULTURE WITH THE ARCC MODEL In reviewing the ARCC model, the EBP team finds that its aim is to provide hospitals and health care systems with an organized conceptual framework to guide system-wide implementation and sustainability of EBP for the pur- pose of improving quality of care and patient outcomes. In addition, this model can be used to achieve a “high reliability” organization (one that delivers safe and high- quality care), decrease costs, and improve clinicians’ job satisfaction. Four assumptions are basic to the ARCC model3: • Both barriers to and facilitators

of EBP exist for individuals and within health care systems.

• Barriers to EBP must be re- moved or mitigated and facili- tators put in place in order for individuals and health care sys – tems to implement EBP as a standard of care.

• For clinicians to change their practices to be evidence based, both their beliefs about the value of EBP and their confi- dence in their ability to imple- ment it must be strengthened.

• An EBP culture that includes EBP mentors is necessary in order to advance and sustain EBP in individuals and health care systems. The first step in the ARCC

model is to assess the organiza- tion’s culture and readiness for EBP (see Figure 1). From that assess- ment, the strengths and limita tions of implementing EBP within the organization can be identified. The key implementation strategy in the ARCC model is the development of a cadre of EBP mentors, who are typically advanced practice nurses or clinicians with in-depth knowledge of and skills in EBP and in individual behavior change

ajn@wolterskluwer.com AJN ▼ September 2011 ▼ Vol. 111, No. 9 59

Developing a cadre of EBP mentors

system-wide is key to the ongoing

implementation and sustainability of

EBP in an organization.

 

 

Wiley-Blackwell; Sigma Theta Tau; 2010. p. 169-84.

4. Melnyk BM, et al. Nurses’ perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: im – plications for accelerating the para- digm shift. Worldviews Evid Based Nurs 2004;1(3):185-93.

5. Levin RF, et al. Fostering evidence- based practice to improve nurse and cost outcomes in a community health setting: a pilot test of the advancing research and clinical practice through close collaboration model. Nurs Adm Q 2011;35(1):21-33.

6. Melnyk BM, et al. The evidence- based practice beliefs and implemen- tation scales: psychometric properties of two new instruments. Worldviews Evid Based Nurs 2008;5(4):208-16.

7. Melnyk BM, et al. Correlates among cognitive beliefs, EBP implementa- tion, organizational culture, cohesion and job satisfaction in evidence-based practice mentors from a community hospital system. Nurs Outlook 2010; 58(6):301-8.

8. Wallen GR, et al. Implementing evidence-based practice: effectiveness of a struc tured multifaceted mentor- ship programme. J Adv Nurs 2010; 66(12):2761-71.

Practice. Contact author: Berna dette Mazurek Melnyk, melnyk.15@osu.edu. The authors have disclosed no potential conflicts of inter est, financial or other- wise.

REFERENCES 1. Melnyk BM, Wiliamson KM. Using

evidence-based practice to enhance organizational policies, healthcare qual – ity, and patient outcomes. In: Hinshaw AS, Grady PA, editors. Shaping health policy through nursing research. New York: Springer Publishing Company; 2011. p. 87-98.

2. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best prac- tice. Philadelphia: Wolters Kluwer Health/Lippincott Williams and Wil- kins; 2011.

3. Melnyk BM, Fineout-Overholt E. ARCC (Advancing Research and Clini- cal prac tice through close Collabora- tion): a model for system-wide implementation and sustainability of evidence-based practice. In: Rycroft- Malone J, Bucknall T, editors. Models and frame works for implementing evidence-based practice: linking evi- dence to action. Oxford; Ames, IA:

the answer to your question— because EBP, not practices steeped in tradition, is the only way we do it here!” ▼

Bernadette Mazurek Melnyk is associate vice president for health promotion, uni- versity chief wellness officer, and dean of The Ohio State University College of Nurs – ing in Columbus, where Lynn Gallagher- Ford is director of Transdisciplinary Evidence-Based Practice and Clinical Innovation. Ellen Fineout-Overholt is dean of Professional Studies and chair of the Department of Nursing at East Texas Baptist University in Mar shall, TX. Susan B. Stillwell is clinical professor and associate director of the Center for the Advancement of Evidence-Based Practice at Arizona State Univer sity in Phoenix. At the time this article was written, Ber- nadette Mazurek Melnyk was dean and distinguished foundation professor of nursing in the College of Nurs ing and Health Innovation at Arizona State Uni- versity, where Ellen Fineout-Overholt was clinical pro fessor and director, and Lynn Gallagher-Ford was clinical assistant pro- fessor and assistant director, of the Center for the Advancement of Evidence-Based

Original Article

A Test of the ARCC C© Model Improves Implementation of Evidence-Based Practice, Healthcare Culture, and Patient Outcomes Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FAANP, FNAP, FAAN • Ellen Fineout-Overholt, RN, PhD, FNAP, FAAN • Martha Giggleman, RN, DNP, NEA-BC • Katie Choy, RN, DNP, CNS, NEA-BC

Keywords

ARCC, evidence-based

practice, organizational

culture, patient outcomes

ABSTRACT Background: Although several models of evidence-based practice (EBP) exist, there is a paucity of studies that have been conducted to evaluate their implementation in healthcare settings.

Aim: The purpose of this study was to examine the impact of the Advancing Research and Clinical practice through close Collaboration (ARCC) Model on organizational culture, clinicians’ EBP beliefs and EBP implementation, and patient outcomes at one healthcare system in the western United States.

Design: A pre-test, post-test longitudinal pre-experimental study was conducted with follow-up immediately following full implementation of the ARCC Model.

Setting and Sample: The study was conducted at a 341-bed acute care hospital in the western region of the United States. The sample consisted of 58 interprofessional healthcare professionals.

Methods: The ARCC Model was implemented in a sequential format over 12 months with the key strategy of preparing a critical mass of EBP mentors for the healthcare system. Healthcare professionals’ EBP beliefs, EBP implementation, and organizational culture were measured with valid and reliable instruments. Patient outcomes were collected in aggregate from the hospital’s medical records.

Results: Findings indicated significant increases in clinicians’ EBP beliefs and EBP implementation along with positive movement toward an organizational EBP culture. Study findings also indicated substantial improvements in several patient outcomes.

Linking Evidence to Action: Implementation of the ARCC Model in healthcare systems can en- hance clinicians’ beliefs and implementation of evidence-based care, improve patient outcomes, and move organizational culture toward EBP.

INTRODUCTION AND BACKGROUND It is well known that evidence-based practice (EBP) improves healthcare quality, safety, and patient outcomes as well as fos- ters clinicians’ active engagement in their practices. Nurses who use an evidence-based approach to care and practice in cultures that support EBP are more empowered as they are able to make a difference in the care of their patients. Although the positive impact of EBP has been demonstrated through multiple studies, major barriers exist that prevent EBP from becoming the standard of care throughout the world. These barriers include (a) inadequate EBP knowledge and skills of clinicians, (b) misperceptions that EBP takes too much time, (c) organizational culture and politics, (d) lack of support from nurse leaders and managers, and (e) inadequate resources and investment in EBP (Jun, Kovner, & Stimpfel, 2016; Melnyk et al., 2016; Melnyk, Fineout-Overholt, Gallagher-Ford, & Ka-

plan, 2012). Aside from equipping clinicians with the knowl- edge and skills needed to attain the EBP competencies and con- sistently implement evidence-based care, findings from studies have indicated that clinician access to EBP mentors can play a key role in their implementation of EBP and the development of organizational cultures that support the delivery of evidence- based care (Fineout-Overholt & Melnyk, 2015; Melnyk, 2007).

Although several EBP models exist, most are process mod- els that outline the steps of EBP or the sequence of conducting an EBP project. EBP process models include the Johns Hopkins Nursing Evidence-Based Practice Model (Dearholt & Dang, 2012), the Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001), the Model for Evidence-Based Practice Change (Rosswurm & Larabee, 1999), and the ACE Star Model of Knowledge Transformation (Stevens, 2012). Unlike EBP process models, the Advancing Research and

Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9. 5 C© 2016 Sigma Theta Tau International

 

 

A Test of the ARCC C© Model Improves Implementation of Evidence-Based Practice

Figure 1. The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model.

Clinical practice through close Collaboration (ARCC) Model is a system-wide model to advance and sustain EBP in healthcare systems (see Figure 1). The first step in implementing the ARCC Model is an organizational assessment of the current EBP culture in order to identify strengths and major barriers to EBP in the healthcare system so that strategies can be implemented to remove those barriers. At the core of the ARCC Model is a critical mass of EBP mentors who, through intentional strategic initiatives, assist point of care clinicians in enhancing their beliefs about the value of EBP and their confidence in implementing it. As a result, ARCC contends that heightened EBP beliefs in clinicians result in greater implementation of evidence-based care, which ultimately leads to higher job satisfaction, less staff turnover, and improved patient outcomes. Several studies now support the relationships among key constructs in the ARCC Model (Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011; Melnyk, 2012; Melnyk & Fineout-Overholt, 2002; Melnyk et al., 2004; Melnyk, Fineout-Overholt, & Mays, 2008; Melnyk, Fineout- Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010).

AIM The purpose of this study was to examine the impact of the ARCC Model on organizational culture, clinicians’ EBP beliefs and EBP implementation, and patient outcomes at one health- care system in the western region of the United States.

DESIGN A pre-test, post-test longitudinal pre-experimental study was conducted with follow-up immediately following full imple- mentation of the ARCC Model. Institutional Review Board ap- proval was obtained from the authors’ institution as well as the organization’s research subject review board.

SETTING AND SAMPLE This study was conducted at Washington Hospital Healthcare System, a 341-bed acute care hospital in the San Francisco bay area. The sample consisted of 58 interprofessional health- care professionals, with complete follow-up data for 45 partic- ipants. Participants were point of care nurses, administrators, nurse managers, clinical nurse specialists, respiratory thera- pists, occupational therapists, physical therapists, dieticians, social workers, and pharmacists. Although physician cham- pions participated in the projects, they were not part of the data collection. Only the project teams participated in data collection.

METHODS The ARCC Model was implemented in a sequential format over 12 months with the key strategy of preparing a critical mass of EBP mentors for the healthcare system. Intensive EBP workshops were first provided to the 58 participants in order to enhance their knowledge and skills in the seven steps of

6 Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9. C© 2016 Sigma Theta Tau International

 

 

Original Article Table 1. Examples of PICOT Questions Formulated by the EBP Teams

� In ventilated intensive care unit patients (P), how does early ambulation (I) compared to routinely scheduled ambulation (C) affect length of stay and episodes of ventilator associated pneumonia while in the intensive care unit (T)

� In congestive heart failure patients (P), how does comprehensive pre-discharge education (I) compared to standard pre-discharge education (C), affect readmission rates to the hospital (O)?

EBP. In addition, content and skills building in the workshops focused on how to facilitate individual behavior change of clin- icians to implement EBP and how to facilitate an EBP organi- zational culture. The 58 participants were divided into working teams of six to eight members who were to collaborate on an EBP change project to improve patient outcomes within the hospital. Each team was then charged with formulating a PICOT (Patient population, Intervention or Issue of inter- est, Comparison intervention or issue, Outcome, and Time for the intervention to achieve the outcome if relevant) question about an important clinical issue, systematically searching for the best evidence, and critically appraising and synthesizing the evidence culminating in a recommendation for practice. See Table 1 for examples of PICOT questions developed by the teams. Strategic plans were then developed by the inter- professional EBP mentor teams to implement and evaluate the impact of the EBP changes on clinical outcomes within their organization. After implementation and evaluation of the prac- tice changes were completed, the final step for the teams was to submit their projects for presentation at local, regional, or national conferences to disseminate their successes to others within the healthcare community.

OUTCOMES Study variables were measured with the following valid and reli- able instruments. The Evidence-Based Practice Beliefs (EBPB) Scale Melnyk & Fineout-Overholt, 2003a) measured clinicians’ beliefs about EBP and their ability to implement it. The 16-item Likert scale has established face, content, and construct valid- ity with internal consistency reliabilities greater than .85 across multiple studies (Melnyk et al., 2008). Responses on the scale range from 1 (strongly disagree) to 5 (strongly agree). Examples of items on the scale include (a) I am clear about the steps in EBP, (b) I am sure that I can implement EBP, and (c) I am sure that evidence-based guidelines can improve care.

The Evidence-Based Practice Implementation (EBPI) Scale measured delivery of evidence-based care (Melnyk & Fineout- Overholt, 2003b). Participants respond to each of the 18 Likert scale items on the EBPI by answering how often in the last eight weeks they have performed certain EBP activities, such as (a) generated a PICOT question about my practice, (b) used evi-

dence to change my clinical practice, (c) evaluated the outcomes of a practice change, and (d) shared the outcome data collected with colleagues. The EBPI has established face, content, and construct validity as well as internal consistency reliabilities greater than .85 across multiple studies (Melnyk et al., 2008).

The Organizational Culture and Readiness Scale for System-Wide Integration of Evidence-Based Practice (OCR- SIEP) measured the organization’s culture and its readiness for system-wide EBP (Fineout-Overholt & Melnyk, 2006). This instrument contains 26 Likert scale items that identify a de- scription of the existing support in the current culture for EBP, which offers insight into the strengths and opportunities for fostering evidence-based care within a healthcare system. The OCRSIEP scale has established face and content validity along with excellent internal consistency reliability of greater than .85 across multiple samples (Melnyk & Fineout-Overholt, 2015). Examples of items on the OCRSIEP include the following: (a) To what extent is EBP clearly described as central to the mission and philosophy of your institution? (b) To what extent do you believe that EBP is practiced in your organization? And (c) To what extent is the nursing staff with whom you work committed to EBP?

Patient Outcomes Aggregate data were gathered by the teams, including data from the hospital’s medical records (e.g., number of cases of ventilator associated pneumonia, hospital readmission rates) before and after implementation of the ARCC Model to evaluate relevant patient outcomes as results of the EBP projects.

Analyses T tests and effect sizes were calculated for study variables to evaluate pre-to-post differences. A p value of .05 was set for statistical significance.

RESULTS Findings indicated that the clinicians’ EBP beliefs, EBP im- plementation, and movement of organizational culture toward EBP significantly increased over the 12-month project. Specif- ically, clinicians’ EBP beliefs (n = 45) increased significantly from baseline (M = 60.7, SD = 7.6) to follow-up (M = 64.9, SD = 6.7; t = 4.2; p = .00; effect size = .62, which is a medium to large positive effect for ARCC). EBP implementation also significantly increased from baseline (M = 17.8, SD = 10.3) to follow-up (M = 51.9, SD = 16.8; t = 12.9; p = .00; effect size = 2.3, indicating a large positive effect for ARCC). In addition, organizational culture and readiness for EBP increased signifi- cantly from baseline (M = 80.9; SD = 90.8) to follow-up (M = 90.8; SD = 14.7; t = 3.9; p = .00; effect size = .70, which is a medium to large positive effect for ARCC). In addition, as a result of implementing the ARCC Model, evidence-based interventions improved key patient outcomes (see Table 2).

Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9. 7 C© 2016 Sigma Theta Tau International

 

 

A Test of the ARCC C© Model Improves Implementation of Evidence-Based Practice

Table 2. Project Outcomes From Implementation of the EBP Changes

� A practice change to early ambulation in the ICU led to a 2.7 reduction in ventilator days (11.6–8.9) and no ventilator associated pneumonia.

� With the implementation of a pressure ulcer prevention nursing standardized procedure on a medical-surgical unit, the acquired pressure ulcer rate was significantly decreased from 6.07% to 0.62% 1 year later.

� Comprehensive education of congestive heart failure patients led to a 14.7% reduction in hospital readmissions.

� After implementation of family centered care on the pediatric unit, 75% of parents perceived the overall quality of care as excellent compared to 22% pre-implementation.

� The percentage of mothers not supplementing their breast milk with formula increased from 61.7% to 71.1% after the evidence-based baby friendly hospital initiative was implemented.

� After implementation of a nurse-initiated pain protocol in the emergency room (ER), wait time for pain medication decreased from 46 minutes to 13 minutes and length of stay in the ER also decreased from 120 minutes to 91 minutes.

DISCUSSION Findings support the positive impact of implementing the ARCC Model on clinicians’ EBP beliefs and a dramatic in- crease in EBP implementation in those who participated in the project. Organizational culture at the hospital shifted greatly toward system-wide EBP. Most important, as a result of imple- menting ARCC, there were multiple improvements in patient outcomes.

The establishment of a cadre of EBP mentors is cen- tral to building an organizational culture of EBP and im- plementing evidence-based care. The EBP mentors in this study garnered the knowledge and skills needed to successfully implement and evaluate EBP changes within the hospital as well as to work with their colleagues in creating an EBP culture in which to deliver high-quality evidence-based care. These findings affirm that culture eats strategy and assists clini- cians in making EBP the social norm within a system (Mel- nyk, 2016b). Without a culture and environment that supports EBP, high-quality evidence-based care will not sustain (Melnyk, 2016a).

Numerous healthcare systems and hospitals throughout the United States and globe have implemented the ARCC Model in their efforts to build and sustain an EBP culture and environ- ment in their organizations. As a part of building this culture, position descriptions have been created or changed to include responsibilities as an EBP mentor. For example, at The Ohio State University Wexner Medical Center, the primary responsi- bility of the clinical nurse specialists throughout the healthcare system is to serve as EBP mentors for point of care staff in improving patient outcomes. Part of this role is ensuring

compliance with the EBP competencies for advanced practice nurses (Melnyk, Gallagher-Ford, & Fineout-Overholt, 2016; Melnyk, Gallagher-Ford, Long & Fineout-Overholt, 2015).

Research is needed to further confirm the advantages of using particular EBP models in real-world practice settings, including how implementation of these models impact both clinician, leader and patient outcomes (Dang et al., 2015). Com- parative effectiveness studies that evaluate the benefits of in- dividual models as well as combining models also are needed. Those hospitals and systems who use an EBP model to guide implementation of evidence-based care should document their experiences and outcomes in order to better understand the model’s usefulness in facilitating EBP and share this impor- tant information with others who might use the model (Gra- ham, Tetroe, & KT Theories Research Group, 2007). Return on investment by including cost outcomes also should be eval- uated. WVN

LINKING EVIDENCE TO ACTION

� The ARCC Model is an evidence-based system- wide model for advancing the implementation and sustainability of EBP.

� A key strategy in the ARCC model is the develop- ment of a critical mass of EBP mentors who assist point of care clinicians in the consistent imple- mentation of evidence-based care.

� Use of ARCC EBP mentors enhances the EBP be- liefs and EBP implementation of clinicians and strengthens the EBP culture of an organization.

� An organizational culture of EBP is central to sup- porting sustainable high quality evidence-based care.

� Implementation of the ARCC Model can substan- tially improve patient outcomes.

Author information

Bernadette Mazurek Melnyk, Associate Vice President for Health Promotion, University Chief Wellness Officer, Dean and Professor, College of Nursing, Professor of Pediatrics & Psychiatry, and College of Medicine, The Ohio State Univer- sity, Columbus, Ohio; Ellen Fineout-Overholt, Mary Coulter Dowdy Distinguished Professor of Nursing, College of Nurs- ing & Health Sciences University of Texas at Tyler, Tyler, Texas; Martha Giggleman, Healthcare Consultant & Advocate Liver- more, California; Katie Choy, Senior Director, Nursing Practice and Education, Washington Hospital Healthcare System, Fre- mont, California

8 Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9. C© 2016 Sigma Theta Tau International

 

 

Original Article Address correspondence to Dr. Bernadette Mazurek Melnyk,

The Ohio State University, 145 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210; Melnyk.15@osu.edu

Accepted 16 September 2016 Copyright C© 2017, Sigma Theta Tau International

References Dang, D., Melnyk, B. M., Fineout-Overholt, E., Ciliska, D., Di-

Censo, A., Cullen, L., . . . & Stevens, R. K. (2015). Models to guide implementation and sustainability of evidence-based prac- tice. In B. M. Melnyk & E. Fineout-Overholt (Eds.) Evidence-based practice in nursing & healthcare. A guide to best practice (3rd ed., pp. 274–315). Philadelphia, PA: Wolters Kluwer.

Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence- based practice model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.

Fineout-Overholt, E., & Melnyk, B. M. (2015). ARCC evidence- based practice mentors: The key to sustaining evidence-based practice. In B. M. Melnyk & E. Fineout-Overholt (Eds.) Evidence- based practice in nursing & healthcare. A guide to best practice (3rd ed., pp. 376–385). Philadelphia, PA: Wolters Kluwer.

Fineout-Overholt, E., & Melnyk, B. M. (2006). Organizational cul- ture and readiness scale for system-wide integration of evidence-based practice. Gilbert, AZ: ARCC, llc.

Graham, I. D., & Tetroe, J. & the KT Theories Research Group. (2007). Some theoretical underpinnings of knowledge transla- tion. Academic Emergency Medicine, 14(11), 936–941.

Jun, J., Kovner, C. T., & Stimpfel, A. W. (2016). Barriers and facilitators of nurses’ use of clinical practice guidelines: An integrative review. International Journal of Nursing Studies, 60, 54–68.

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doi 10.1111/wvn.12188 WVN 2017;14:5–9

Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9. 9 C© 2016 Sigma Theta Tau International

 

 

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Implementing an Evidence-Based Practice Change Beginning the transformation from an idea to reality.

This is the ninth article in a series from the Arizona State University College of Nursing and Health Innovation’s Cen- ter for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every other month to allow you time to incorporate information as you work to – ward implementing EBP at your institution. Also, we’ve scheduled “Chat with the Authors” calls every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be published with May’s Evidence-Based Practice, Step by Step.

I n January’s evidence-based prac tice (EBP) article, Rebe -cca R., our hypothetical staff nurse, Carlos A., her hospital’s ex pert EBP mentor, and Chen M., Rebecca’s nurse colleague, began to develop their plan for implementing a rapid response team (RRT) at their institution. They clearly identified the pur- pose of their RRT project, the key stakeholders, and the vari- ous outcomes to be measured, and they learned their internal re view board’s requirements for re viewing their pro posal. To de- termine their next steps, the team consults their EBP Implementa- tion Plan (see Figure 1 in “Fol- lowing the Evidence: Plan ning for Sustainable Change,” Jan – uary). They’ll be working on items in checkpoints six and

seven: specif ically, engaging the stakeholders, getting administra- tive support, and preparing for and conducting the stakeholder kick-off meeting.

ENGAGING THE STAKEHOLDERS Carlos, Rebecca, and Chen reach out to the key stakeholders to tell them about the RRT project by meeting with them in their offices or calling them on the phone. Car – los leads the team through a dis- cussion of strategies to promote success in this critical step in the implementation process (see Strat ­ egies to Engage Stakeholders). One of the strategies, connect in a col­ laborative way, seems espe cially applicable to this project. Each team member is able to meet with a stakeholder in person, fill them in on the RRT project, describe the purpose of an RRT, discuss their role in the project, and an – swer any questions. They also tell each stakeholder about the initial project meeting to be held in a few weeks.

In anticipation of the stake- holder kick-off meeting, Carlos and the team discuss the fun – damen tals of preparing for an

im portant meeting, such as how to set up an agenda, draft key doc- uments, and conduct the meet – ing. They begin to discuss a time and date for the meeting. Carlos suggests that Rebecca and Chen meet with their nurse manager to up date her on the project’s pro gress and request her help in sched uling the meeting.

SECURING ADMINISTRATIVE SUPPORT After Rebecca updates her man- ager, Pat M., on the RRT pro ject, Pat says she’s impressed by the team’s work to date and of fers to help them move the project forward. She suggests that, since they’ve already invited the stake- holders to the upcoming meet ing, they use e-mail to communicate the meeting’s time, date, and place. As they draft this e-mail together, Pat shares the follow – ing tips to im prove its effective- ness: • communicate the essence and

importance of the e-mail in the subject line

• write an e-mail that’s engaging, but brief and to the point

• introduce yourself • explain the project

54 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com

Strategies to Engage Stakeholders • Spend time and effort building trust. • Understand stakeholders’ interests. • Solicit input from stakeholders. • Connect in a collaborative way. • Promote active engagement in establishing

metrics and outcomes to be measured.

 

 

By Lynn Gallagher-Ford, MSN, RN, NE-BC, Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN, Bernadette

Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, and Susan B. Stillwell, DNP, RN, CNE

• welcome the recipients to the project and/or team and invite them to the meeting

• explain why their attendance is critical

• request that they read certain materials prior to the meeting (and attach those documents to the e-mail)

• let them know whom to con- tact with questions

• request that they RSVP • thank them for their partici-

pation Before they send the e-mail (see Sample E­mail to RRT and Stake­ holders), the team wants to make sure they don’t miss anyone, so they review and include all of the RRT members and stake holders. They realize that it’s im portant to invite the manager of each of the stakeholders and disciplines rep- resented on the RRT and ask

them to also bring a staff represen- tative to the meeting. In addition, they copy the administrative di rec – tors of the stakeholder depart- ments on the e-mail to en sure that they’re fully aware of the project.

PREPARING FOR THE KICK-OFF MEETING The group determines that the draft documents they’ll need to prepare for the stakeholder kick- off meeting are: • an agenda for the meeting • the RRT protocol • an outcomes measurement plan • an education plan • an implementation timeline • a projected budget To expedite completion of the doc- uments, the team divides them up among themselves. Chen volun- teers to draft the RRT protocol and outcomes measurement plan.

Carlos assures her that he’ll guide her through each step. Rebecca decides to partner with her unit ed- ucator to draft the education plan. Carlos agrees to take the lead in drafting the meeting agenda, im – plementation timeline, and pro- jected budget, but says that since this is a great learning opportu- nity, he wants Rebecca and Chen to be part of the drafting process.

Drafting documents. Carlos tells the team that the purpose of a draft is to initiate discussion and give the stakeholders an oppor tu – nity to have input into the final prod uct. All feedback is a positive sign of the stakeholders’ involve- ment, he says, and shouldn’t be per ceived as criticism. Carlos also offers to look for any tem- plates from other EBP projects that may be helpful in drafting the documents. He tells Rebecca

ajn@wolterskluwer.com AJN ▼ March 2011 ▼ Vol. 111, No. 3 55

Sample E-mail to RRT and Stakeholders To: ICU Nurse Manager, 3 North Nurse Manager, Respiratory Therapy Director, Medical Director of ICU, Director of Acute Care NP Hospitalists, Director of Spirituality Department

cc: EBP Council Chair, VP Nursing, VP Medical Affairs, ICU Nursing Director, Medical–Surgical Nursing Director, Finance Department Director, Communications Department Director, Risk Management Director, Education Department Director, HIMS (Medical Records) Director, Quality/Performance Improvement Director, Clinical Informatics Director, Pharmacy Director

Subject: Invitation to the Rapid Response Project Stakeholder Kick-off Meeting

Good afternoon. I would like to introduce myself. My name is Rebecca R. I am a staff nurse III on the 3 North medical– surgical unit. You have either spoken with me or with one of my colleagues, Carlos A. or Chen M., about an important evidence-based initiative that will help improve the quality of care for our patients. The increasing patient acuity on our unit and throughout the hospital, and the frequent need for patients to be transferred to the ICU, prompted us to ask important questions about patient outcomes. For the past few months, Carlos, Chen, and I have been investigating how our hospital can reduce the number of codes, particularly outside the ICU. We have conducted a thorough search for and appraisal of current available evidence, which we would like to share with you.

Our team and our managers would like to invite you to participate in a kick-off meeting to discuss an exciting evidence-based initiative to improve the quality of patient care in our hospital. The meeting will be held on March 1, 2011, at 10 am in the Innovation Conference Room on the 2nd floor. It is very important that you attend this meeting as you have been identified as a critical participant in this project. We need your input and support as we move for- ward. So please plan to attend the meeting or send a representative. To ensure that we have sufficient materials for the meeting, please RSVP to Mary J., unit secretary on 3 North.

I want to thank you in advance for your help with and support of this project. I look forward to seeing you at the meeting. If you have any questions, please feel free to contact me or any of the RRT project team members.

Rebecca R. and the RRT Project Team

 

 

56 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com

RRT Protocol Draft for Review Current evidence supports the effectiveness of an RRT in decreasing adverse events in patients who exhibit specific clinical parameters. Evidence-based recommendations include that RRTs should be available on general units of hospitals, 24 hours a day and seven days a week, staffed by intensive care clinicians, and activated based on established clinical criteria. The RRT serves a dual purpose of pro- viding both early intervention care to at-risk patients and education in recognizing and managing these patients to clin ical staff.

The RRT is available to respond to and assist bedside staff in caring for patients who develop signs or symptoms of clinical deterio- ration.

RRT Members RRT members are all ACLS certified. They include: Team Leader: Acute Care NP Hospitalist (credentialed in advanced procedures) Team Members: ICU RN

Respiratory Therapist (trained in intubation) Physician Intensivist (ICU MD on call and available to the RRT) Hospital Chaplain

Initiation of RRT Consult An RRT consult can be initiated by any bedside clinician. Consults should be initiated based on the following patient status criteria.

RRT Consult Initiation Criteria

Pulmonary

Ventilation: Color change (pale, dusky, gray, or blue)

Respiratory distress: RR < 10 or > 30 breaths/min, or Unexplained dyspnea, or New-onset difficulty breathing, or Shortness of breath

Cardiovascular

Tachycardia: Unexplained > 130 beats/min for 15 mins

Bradycardia: Unexplained < 50 beats/min for 15 mins

Blood pressure: Unexplained SBP < 90 or > 200 mmHg

Chest pain: Complaint of nontraumatic chest pain

Pulse oximetry: < 92% SpO2 Perfusion: UOP < 50 cc/4 hr

Neurologic

Seizures: Initial, repeated, or prolonged

Change in mental status: Sudden decrease in LOC with normal blood sugar Unexplained agitation for > 10 min New-onset limb weakness or smile droop

Sepsis

Clinical indicators of sepsis: Temperature > 38ºC

HR > 90 beats/min

RR > 20 breaths/min

WBC > 12,000, < 4,000

Nurse’s concern about overall deterioration in patient’s condition without any of the above criteria.

Scope of the RRT The RRT can be expected to perform any/all of the following interventions: Nasopharyngeal/oropharyngeal suctioning Oxygen therapy

 

 

ajn@wolterskluwer.com AJN ▼ March 2011 ▼ Vol. 111, No. 3 57

Initiation of CPAP Initiation of nebulized medications Intravenous fluid bolus(es) Intravenous fluid bolus(es) with medication CPR

The RRT can be expected to perform any/all of the following invasive procedures: Endotracheal intubation Intravenous line insertion Intraosseous line insertion Arterial line insertion Central line insertion

RRT Consult Procedure 1. Assess patient relative to the above criteria. 2. If any of the above criteria are identified, initiate the RRT consult by calling 5-5555. The operator will request the caller’s location,

the patient’s name, the patient’s location, and the reason for RRT activation. This call will generate both pages to the RRT members and an overhead announcement.

3. The RRT will arrive within five minutes (or less) of the call. 4. Be prepared to provide the RRT with appropriate information about the patient using the SBAR communication method. (See stan-

dardized communication protocol no. 7.) 5. While awaiting the arrival of the RRT, consider initiating any/all of the following actions:

• Call for a colleague to help you • Set up oxygen apparatus • Set up suction apparatus • Call for the code cart to be brought to the area • Communicate with the patient’s family (if present); tell them what you’re doing and why and that someone will be here shortly

to help them • Obtain proper documentation tools to be used during the RRT consult

RRT Arrival When the RRT arrives: 1. Provide information as indicated above. 2. Participate in the care of your patient and remain with the patient and the RRT. 3. Assist the RRT as needed. 4. Document activities, interventions performed, and patient responses to interventions. 5. Work with the chaplain to ensure that the patient’s family is informed of the situation at intervals. 6. Assist in arranging for transfer of the patient to a higher level of care if indicated. 7. Provide a detailed report to the nurse accepting the patient on the receiving unit, utilizing the SBAR communication method.

ACLS = advanced cardiac life support; cc = cubic centimeters; CPAP = continuous positive airway pressure; CPR = cardiopulmonary resusci- tation; hr = hours; HR = heart rate; ICU = intensive care unit; LOC = level of consciousness; MD = medical doctor; min = minute; mmHg = millimeters of mercury; NP = nurse practitioner; RN = registered nurse; RR = respiratory rate; RRT = rapid response team; SBAR = situation- background-assessment-recommendation; SBP = systolic blood pressure; SpO2 = arterial oxygen saturation; UOP = urine output; WBC = white blood count.

REFERENCES 1. Choo CL, et al. Rapid response team: a proactive strategy in managing haemodynamically unstable adult patients in the acute care hospitals.

Singapore Nursing Journal 2009;36(4);17-22. 2. Winters BD, et al. Rapid response systems: a systematic review. Crit Care Med 2007;35(5):1238-43. 3. Hillman K, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005;365(9477):2091-7. 4. Sharek PJ, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA 2007;

298(19):2267-74. 5. Mailey J, et al. Reducing hospital standardized mortality rate with early interventions. J Trauma Nurs 2006;13(4):178-82. 6. Dacey MJ, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007;35(9):

2076-82. 7. Benson L, et al. Using an advanced practice nursing model for a rapid response team. Jt Comm J Qual Patient Saf 2008;34(12):743-7. 8. Hatler C, et al. Implementing a rapid response team to decrease emergencies. Medsurg Nurs 2009;18(2):84-90, 126. 9. Bader MK, et al. Rescue me: saving the vulnerable non-ICU patient population. Jt Comm J Qual Patient Saf 2009;35(4):199-205. 10. DeVita MA, et al. Use of medical emergency team responses to reduce cardiopulmonary arrests. Qual Saf Health Care 2004;13(4):251-4.

 

 

58 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com

and Chen that he’s confident they’ll do a great job and shares his ex – cite ment at how the team has pro- gressed in planning an EBP practice change.

RRT protocol. Chen starts to draft the RRT protocol using one of the hospital’s protocols as a tem plate for the format, as well as definitions and examples of protocols, policies, and proce- dures from other organizations and the literature. She returns to the articles from the team’s origi- nal literature search (see “Critical Appraisal of the Evidence: Part I,” July 2010) to see if there is infor- mation, previously appraised, that will be helpful in this current step in the process. She recalls that the team had set aside some articles be cause they didn’t directly an – swer the PICOT question about whether to implement an RRT, but they did have valuable infor- mation on how to implement an RRT. In reviewing these articles, Chen selects one that’s a review of the literature, though not a sys tematic review, that includes

many examples of RRT member- ship rosters and protocols used in other hospitals, and which will be help ful in drafting her RRT protocol document.1 Chen includes this ex pert opinion ar- ticle be cause the informa tion it contains is consistent with the higher-level evidence already being used in the project. Using both higher and lower levels of evidence, when appropriate, al – lows the team to use the best infor – mation available in formulating their RRT protocol.

As she writes, Chen discovers that their hospital’s protocols and other practice documents don’t in – clude a section on supporting evi- dence. Knowing that evidence is critically important to the RRT pro tocol, she discusses this with the clinical practice council represen- tative from her unit who advises her to add the section to her draft document. He promises to present this issue at the next coun cil meet – ing and obtain the council’s ap – proval to add an evidence section to all future practice documents.

Chen reviews the finished product before she submits it for the team’s review (see RRT Protocol Draft for Review1-10).

Outcomes measurement plan. Based on the appraised evidence and the many discussions Rebe – cca and Chen have had about it, Chen drafts a document that lists the outcomes the team will mea- sure to demonstrate the success of their project, where they’ll ob tain this information, and who will gather it (see Table 1). In draf ting this plan, Chen realizes that they don’t have all the information they need, and she’s concerned that they’re not ready to move for ward with the stakeholder kick- off meeting. But when Chen calls Carlos and shares her con- cern, Car los reminds her that the document is a draft and that the re quired information will be ad – dressed at the meeting.

Education plan. Rebecca reaches out to Susan B., the clin ical educator on her unit, and requests her help in drafting the education plan. Susan tells Rebe cca how much

Table 1. Plan for Measuring RRT Success (Draft for Discussion)

Outcome Measurement Source/Owner

CRO • Codes outside of the ICU • EMR

Mortality rates: HMR and NIM

• Hospital mortality rates by unit • Discuss at meeting

UICUA • ICU admissions  planned  unplanned

• EMR; ICU admissions database; check box needed to indicate planned and unplanned

Return on RRT investment (cost of RRT compared with savings due to RRT)

1. Cost of RRT • Personnel • Supplies

2. Savings due to RRT • Cost of UICUA • Number of UICUA prevented

• RRT personnel cost/hour

• UICUA cost/day • LOS for average UICUA • Number of UICUA prevented

• Billing data • RRT response time and end time as re­

corded on the RRT data documentation tool

• Billing data • Disposition of RRT call as recorded on the

RRT data documentation tool

CRO = code rates outside the ICU; EMR = electronic medical record; HMR = hospital-wide mortality rates; ICU = intensive care unit; LOS = length of stay; NIM = non-ICU mortality; RRT = rapid response team; UICUA = unplanned ICU admissions.

 

 

ajn@wolterskluwer.com AJN ▼ March 2011 ▼ Vol. 111, No. 3 59

she enjoys the op portunity to work collaboratively with staff nurses on education pro jects and how happy she is to see an EBP project being implemented. Rebecca shares her RRT project folder (containing all the informa tion relative to the pro- ject) with Susan, focusing on the education about the project she thinks the staff will need. Susan commends the team for its efforts, as a good deal of the necessary work is al ready done. She asks Rebecca to clarify both the ulti- mate goal of the project and what’s most im por tant to the team about its rollout on the unit. Rebecca thoughtfully responds that the ultimate goal is to ensure that patients re ceive the best care possi- ble. What’s most im portant about its rollout is that the staff sees the value of an RRT to the patients and its positive impact on their own workload. She adds that it’s

im portant to her that the project be conducted in a way that feels pos itive to the staff as they work to ward sustain able changes in their practices.

Susan and Rebecca discuss which clinicians will need edu – cation on the RRT. They plan to use a variety of mechanisms, in – clud ing in-services, e-mails, news- letters, and flyers. From their conversation, Susan agrees to draft an education plan using a template she developed for this purpose. The template prompts her to put in key elements for planning an education program: learner objectives, key content, methodology, faculty, materials, time frame, and room location. Susan fills the template with in- formation Rebecca has given her, adding information she knows already from her expe rience as an educator. When Rebecca and

Susan meet to re view the plan, Rebecca is amazed to see how their earlier conversation has been transformed into a com- prehensive document (see the Education Plan for RRT Imple­ mentation at http://links.lww. com/AJN/A19).

Agenda and timeline. The team meets to draft the meeting agenda, implementation timeline, and budget. Carlos explains the purposes of a meeting agenda: to serve as a guide for the participants and to promote productivity and efficiency. They draft an agenda that includes the key issues to be shared with the stakeholders as well as time for questions, feed- back, and discussion (see the Rapid Response Team Kick­off Meeting Agenda at http://links. lww.com/AJN/A20).

Carlos describes how the time- line creates a structure to guide

Table 3. RRT Project Budget Draft (Draft for Discussion)

Annual Costs

Item Projected Cost/Unit No. Units Needed

Cost/Year Cost Center Approval Needed

Notes:

RRT pagers $30/month 8/month $2,880 Administration VP Nursing

Data collection

RRT leader, $45/hour

1 hour/month $540 Hospitalist VP Medical Affairs

Data entry Administrative assistant, $15/hour

1 hour/month $180 Nursing administration

Medical– surgical director

Data analysis

Data manager, $21/hour

1 hour/month $252 Quality Quality manager

First Year Start-Up Costs

Education prep

Advanced practice nurse, $45/hour

2 Project leaders, $30/hour

Nurse manager, $40/hour

6 hours

6 hours each

2 hours

$270

$360

$80

Total = $710

3 North Nursing 3 North Nurse manager

Unit educators will schedule their time to provide the in-services. No additional cost.

Education delivery

80 Staff members, $30/hour (average rate)

1/2 hour each $1,200 Departmental education budgets

Department managers

This is the cost for the pilot unit only.

 

 

60 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com

the project (see Table 2 at http:// links.lww.com/AJN/A21). The team further discusses how it can maintain the project’s momen- tum by keeping it moving for- ward while at the same time accommodate unexpected delays or resistance. There are a few items on the timeline that Carlos thinks may be underestimated― for example, the team may need more than a month to meet with other departments because of al- ready heavily scheduled calendars―­ but he decides to let it stand as drafted, knowing that it’s a guide and can be adjusted as the need arises.

Budget. Carlos discusses the budget with the team. Rebecca shares a list of what she thinks they’ll need for the project and the team decides to put this informa- tion into a table format so they can more easily identify any missing information. Before they construct the table, they walk through an imaginary RRT call to be sure they’ve thought of all the budget implications of the project. They realize they didn’t include the cost of each employee attending an education session, so they add that figure to the budget. They also realize that they’re missing hourly pay rates for the different types of employees involved. Car- los tells Rebecca that he’ll work with the Human Resources De- partment to obtain this informa- tion before the meeting so they can complete the budget (see Table 3).

REVIEWING THEIR WORK The next time they meet, the EBP team reviews the agenda for the meeting and the documents they’ll

be presenting. The clerical person on Rebecca and Chen’s floor (some- times called the unit secretary) has kept a record of who’s attend- ing the meeting and the team is pleased that most of the stake- holders are coming. Carlos in- forms the team that he received notification that their internal re- view board submission has been approved. They’re excited to check that step off on their EBP Imple- mentation Plan.

Carlos suggests that they dis- cuss the kick-off meeting in detail and brainstorm how to prepare for any negative responses to their project that might occur. Rebecca

and Chen remark that they’ve never considered that someone might not like the idea of an RRT. Carlos says he’s not surprised; of- ten the passion that builds around an EBP project and the hard work put into it precludes taking time to think about “why not.” The team talks about the importance of stopping occasionally during any project to assess the environ- ment and par ticipants, recogniz- ing that people often have different perspectives and that everyone may not support a change. Carlos reminds the team that people may simply resist changing the routine, and that this can lead to the sabotage of a new idea. As they explore this possible resis- tance, Rebecca shares her concern that with everyone in the hospital so busy, adding something new may be too stressful for some peo- ple. Carlos tells Rebecca and Chen that helping project participants realize they’ll be doing the same thing they’ve been doing, just in a more efficient and effective way, is generally successful in helping them

accept a new process. He reminds them that many of the people on the RRT are the same people who currently take care of patients if they code or are admitted to the ICU; however, with the RRT pro- tocol, they’ll be intervening ear- lier to improve patients’ outcomes. The team feels confident that, if needed, they can use this approach at the kick-off meeting.

CONDUCTING THE KICK-OFF MEETING Rebecca and Chen are both ner- vous and excited about the meet- ing. Carlos has made sure they’re well prepared by helping them set up the meeting room, computer, PowerPoint presentation, and handout packets containing the agenda and draft documents. The team is ready, and they’ve placed themselves at the head of the ta – ble so they can be visible and ac- cessible. As the invitees arrive, they welcome each one individu- ally, thanking them for participat- ing in this important meeting. The team makes sure that the meeting is guided by the agenda and moves along through the presentation of information to thoughtful questions and a lively discussion.

Join the EBP team next time as they launch the RRT project and tackle the real-world issues of project implementation. ▼

Lynn Gallagher­Ford is assistant direc ­ tor of the Center for the Advancement of Evidence­Based Practice at Arizona State University in Phoenix, where Ellen Fineout­Overholt is clinical pro fessor and director, Susan B. Stillwell is associate di ­ rector, and Bernadette Mazurek Melnyk is dean and distinguished foundation pro ­ fessor of nursing at the College of Nursing and Health Innovation. Contact author: Lynn Gallagher­Ford, lynn.gallagher­ford@ asu.edu.

REFERENCE 1. Choo CL, et al. Rapid response team:

a proactive strategy in man aging haemodynamically unstable adult patients in the acute care hospitals. Singapore Nursing Journal 2009; 36(4);17-22.

With the RRT protocol, staff will be intervening earlier to improve

patients’ outcomes.

 

 

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