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TRANSCRIPT
Implementa)on Science and the Direct Care Nurse
Advocate Nursing Research Symposium 6th Annual Symposium
April 17, 2018 Beth VoEero, PhD, RN, CNE Associate Professor, Purdue Northwest Research Associate, Indiana Center for Evidence Based Nursing Prac)ce, A Joanna Briggs Center of Excellence
© 2017 These slides may be copied for noncommercial personal use only without expressed, wriEen consent from the author
• Iden)fy implementa)on strategies that are commonly found in the prac)ce seOng
• Explain the nurse’s role in implemen)ng change
• Apply evidence-‐based implementa)on strategies to a change that considers the type of change, the context for change and the stakeholders involved in the change
Before we begin …
We first need to consider the change to be made before selec)ng implemen)ng strategies: • Is our change based on the best available evidence? – How do we know?
• How do we know if our evidence is good or bad?
Handy Vs Best Available
Handy • Quickly accessible • Local • Google searches • ‘Spoon fed’ evidence or
‘grab and go’ • Does not necessarily mean
the evidence is bad
Best Available • Ac)ve search of databases • ‘Best’ requires an appraisal
of the quality of evidence • ‘Available’ implies that a
search is thorough and considers all evidence
Judging the quality of evidence requires using an appraisal tool
Handy Evidence
• Wolters Kluwer’s Up To Date
• Elsevier’s Clinical Key
• LippincoE’s Nursing Center
Appraisal Tools • CASP:
– hEp://www.casp-‐uk.net/casp-‐tools-‐checklists
• AGREE II:
– hEps://www.agreetrust.org/agree-‐ii/
• JBI:
– hEp://joannabriggs.org/research/cri)cal-‐appraisal-‐tools.html
Consider this… • In 2001, a large mul)-‐site study found that )ght glycemic control (80-‐110mg/dL) reduced mortality in ICU pa)ents (vs. conven)onal treatment of 180-‐200mg/dL)
• Total of 1548 pa)ents enrolled • Findings showed a reduc)on in: – Overall mortality by 34% – Bloodstream infec)ons by 46% – Acute renal failure by 41% – Lowered mechanical ven)la)on and ICU days
Based on these findings Do you think hospitals and organiza)ons: A. Accepted findings and made changes B. Accepted findings but waited for more evidence C. Rejected findings and did things how they were
always done D. Rejected findings but changed prac)ce
Finally, our findings do not support the guidelines of organiza5ons such as the American Diabetes Associa5on, the American Associa5on of Clinical Endocrinologists and other organiza5ons, including the Surviving Sepsis Campaign, who recommend intensive insulin therapy for all cri5cally ill pa5ents.
Ramifica)ons
Evidence
1. The clinical prac)ce guidelines were using evidence from 1 study although it was a mul)site study (common)
2. Subsequent meta-‐analysis considered all studies on the topic and pooled the data to increase the strength of findings (2008: n=34 studies and 2009: n=26)
Ask the Ques)ons…
Does evidence support the change (interven)on)?
Where was the evidence found?
How do I, as the nurse using the evidence, know that it is high
quality?
What appraisal tools were used?
What kind of evidence is it?
Synthesized Evidence for Rapid Use
Next Steps
We have high quality evidence, now what?
Implementa<on Strategies • No one strategy or grouping works for every… – Problem – Person/Group – SeOng – Change
Audit and feedback Ongoing consulta)on Local data sharing Advisory boards Workgroups Iden)fy barriers/facilitators Use data warehousing Tailor strategies Detail educa)on Remind clinicians Implementa)on advisor Build a coali)on Assess for readiness Capture and share knowledge Change structure/equipment Centralize technical assistance Clinical decision supports Educa)onal outreach Dissemina)on organiza)on Staged implementa)on Clinical supervision Integrate clinical records
Powell, B.J., Waltz, T.J., Chinman, M.J., Damschroder, L.J., Smith, J.L., MaEhieu, M.M., Proctor, E., & Kirchner, J.E. (2015). A refined compila)on of implementa)on strategies: Results from the Expert Recommenda)ons for Implemen)ng Change (ERIC) project . Implementa5on Science, 10(21), 1-‐14.
Hot off the press…
Geerligs, L., Rankin, N.M., Shepherd, H.L., & Butow, P. (2018). Hospital-‐based interventions: A systematic review of staff-‐reported barriers and facilitators to implementation processes. Implementation Science, 13(36). https://doi.org/10.1186/s13012-‐018-‐0726-‐9
Ques)on…
How do we retain the key points of our change across seOngs (loca)ons, units, organiza)ons)
considering that resources, skill sets and cultures are varied, yet our outcomes should be
the same?
How do we get there?
Implemen)ng Change
Implementa)on strategies should be selected based on context analysis, stakeholder assessment and be based on the best available evidence
Context
• Complicated concept that includes considera)on for: – Culture – Processes currently embedded in prac)ce – Loca)on, layout – SeOng – People – Communica)on – Etc.
A normal day…
Consider a normal day in your nursing prac)ce • You go into the break room to put away your personal items
• You go into the nursing sta)on to gather data • You conduct change of shir rounding • You document in the electronic record – What ar)facts of implemen)ng change do you think you see?
Stakeholders
• Those individuals who are involved in or are affected by the change
• Cri)cal to understand stakeholder’s influence and support levels
• Best effect comes from knowing and engaging the stakeholders – Let’s look at some tools
hEp://rnao.ca/bpg/resources/toolkit-‐implementa)on-‐best-‐prac)ce-‐guidelines-‐second-‐edi)on
Example of a Stakeholder Engagement Plan
Frequently Used Implementa)on Strategies
• Audit/Feedback • Clinical Decision Support Systems (prompts, cues) • Opinion leaders • Posters (educa)onal materials) • Inservices (educa)onal outreach) • Prompts and Cues • Nudges We will look at each, the evidence and main points
Audit / Feedback
Ivers, N., Jamtvedt, G., FloEorp, S., Young, J.M., Odgaard-‐Jensen, J., French, S.D., O’Brien, M.A., Grimshaw, J.M. & Oxman, A.D. (2012). Audit and feedback: Effects on professional prac)ce and healthcare outcomes. The Cochrane Library, 6. DOI: 10.1002/14651858.CD000259.pub3.
• Evidence Synthesis: – Audit and feedback generally leads to small but poten)ally important improvements in professional prac)ce
– Effec)veness of audit and feedback depends on baseline performance and how feedback is provided
Clinical Decision Support Systems (CDSS)
Evidence Synthesis: • Despite the cumula)ve knowledge of CDSSs, it is s)ll not
possible to draw definite conclusions on their effec)veness, especially for pa)ent outcomes, because of heterogeneity in systems, seOngs, and outcomes assessed
– Improvements in process of care such as chronic disease management processes
– Improved test ordering – All agreed that this is an immature area requiring standardiza)on of CDSS
hEps://www.biomedcentral.com/collec)ons/CCDSS
Opinion Leaders Evidence Synthesis: • The concept of opinion leadership has a good theore)cal basis and
strong face validity. Some trials of recrui)ng opinion leaders to support the implementa)on of research findings have observed significant improvements in clinical care.
– Less effec)ve for large groups (na)onal influence) – More effec)ve for specialized areas (limited spheres of influence) – May change over )me
Grimshaw, J.M.,Eccles, M.P., Greener, J., Maclennan, G., Ibbotson, T., Kahan, J.P., & Sullivan, F. (2006). Hospital-‐based interven)ons: a systema)c review of staff-‐reported barriers and facilitators to implementa)on processes. Implementa5on Science, 61(3). hEps://doi.org/10.1186/1748-‐5908-‐1-‐3 Doumit, G., Wright, F.C., Graham, I.D., Smith, A. & Grimshaw, J. (2011). Opinion leaders and changes over )me: A survey. Implementa5on Science, 6(117). hEps://doi.org/10.1186/1748-‐5908-‐6-‐117
Print Educa)onal Materials
Evidence Synthesis: • When used alone may have a beneficial effect on process outcomes but not on pa)ent outcomes
• When used in conjunc)on with other methods, has a stronger impact
Farmer, A.P., Légaré, F., Turcot, L., Grimshaw, J., Harvey, E., McGowan, J.L., & Wolf, F. (2008). Printed educa)onal materials: effects on professional prac)ce and health care outcomes. Cochrane Database of Systema5c Reviews (3). Art. No.: CD004398. DOI: 10.1002/14651858.CD004398.pub2.
Inservices (Educa)onal Outreach)
Evidence Synthesis: • EO’s alone or when combined with other interven)ons have effects that are rela)vely consistent and small, but poten)ally important
• Their effects on other types of professional performance vary from small to modest improvements
O’Brien, M.A., Rogers, S., Jamtvedt, G., Oxman, A.D., Odgaard-‐Jensen, J., Kristoffersen, D.T., Forsetlund, L., Bainbridge, D., Freemantle, N., Davis, D., Haynes, R.B., & Harvey, E. (2009). Educa)onal outreach visits: Effects on professional prac)ce and health care outcomes. Cochrane Database of Systema5c Reviews, (4). DOI: 10.1002/14651858.CD000409.pub2.
Prompts and Cues
Evidence Synthesis: • Considered a behavioral change technique • Borderline posi)ve effects of technology-‐based strategies
• Need to understand which characteris)cs are effec)ve in promo)ng change
Alkhaldi, G., Hamilton, F. L., Lau, R., Webster, R., Michie, S., & Murray, E. (2016). The Effec)veness of Prompts to Promote Engagement With Digital Interven)ons: A Systema)c Review. Journal of Medical Internet Research, 18(1), e6. hEp://doi.org/10.2196/jmir.4790
Nudges
‘Behavioral Theory’ that suggests changes can occur through sugges)ons that we are unaware of, are low cost yet s)ll offer choices – Alka Seltzer plop, plop, fizz, fizz – Food choice placement – Amsterdam urinal flies
Holds promise for implemen)ng change!
What do we know?
• Strong support that using more than one strategy improves implementa)on
• A minimum of 3 different strategies for beEer outcomes
Case
Problem: A TB syringe used instead of an insulin syringe causing a 10-‐fold overdose
Causes: 1. TB and insulin syringes both had orange caps 2. Both syringe types were stored alongside each other
causing ‘cross-‐contamina)on’ of needles
hEp://www.atlan)cmedsupply.com/needles-‐syringes/tuberculin-‐syringe-‐w/needle-‐1cc-‐25g-‐x-‐5/8/ hEps://www.medshop.com.au/products/bd-‐ultra-‐fine-‐insulin-‐syringes Image sources
Case Stakeholders gathered to examine case and determine changes including several direct care nurses, inventory management, supervisor, charge nurse, quality nurse, pharmacist and CNO Note, the facility espoused a non-‐puni5ve environment and this nurse self-‐reported the error
Priori)es: 1. Order different syringes (orange = insulin, red = TB) 2. Store insulin syringes in a different loca)on than TB
syringes
Case
Implementa)on Strategies 1. Opinion Leaders 2. Posters (educa)onal materials) 3. Inservices (educa)onal outreach) 4. Prompts and Cues 5. Nudges
Role of the Direct Care Nurse • If nurses are: – The last line of defense for pa)ents/popula)ons – Have the most contact with pa)ents/popula)ons – Have in-‐depth knowledge of pa)ents/popula)ons – Are gatekeepers of pa)ent care – Coordinate pa)ent care – Apply interven)ons that directly affect pa)ent care outcomes
Then nurses are cri<cal to any change affec<ng pa<ent care!
Role of the Direct Care Nurse • Key roles:
– Understand changes occurring – Iden)fy clinical problems and report – Ques)on prac)ce – Ask to see the evidence – Recognize implementa)on strategies – Engage in commiEees or councils that work on changes – Provide the nurse’s perspec)ve – Guide others to adhere to changes
• Remember, YOU are the key stakeholder for any change involving pa)ent care!
Thank you for listening!
