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The pervasive problems of the nation’s healthcare system call for increasing numbers of advanced practice registered nurses (APRNs) prepared as highly proficient, competent providers and equipped with evidence-based knowledge and skills to improve the health of the population (Trautman et al., 2018). APRNs are prepared to improve the health and outcomes of patient populations and/or delivery systems. APRNs improve outcomes through systems leadership, quality improvement processes and by translating evidence into practice settings and are well situated to identify clinical problems that require collaborative partnerships and problem-solving skills, using evidence-based resources to improve outcomes and transform systems of care.

The American Association of Colleges of Nursing (AACN) Task Force Report (2015) on the Implementation of the Doctor of Nursing Practice (DNP) defined scholarship as “the mechanism that provides knowledge development within a discipline” and highlighted that nurses with a practice-focused doctorate “are prepared to generate new knowledge through practice innovation” (p. 2). APRNs are prepared to contribute to the scholarly output in the discipline, particularly in the area of clinical practice. APRNs translate knowledge into practice by working with interdisciplinary teams, using translational research methods, and disseminating practice-focused scholarly products.

This chapter describes four APRN-led initiatives implemented across diverse settings including acute care, long-term care, assisted living, and home care. These exemplars highlight how APRNs serve as change agents to improve processes and healthcare outcomes. Key strategies to promote successful change are evident across these exemplars including identifying the problem with data, using evidence-based approaches, collaborating with key stakeholders, and identifying evidence-based methods that were feasible within the specific setting. Moreover, these exemplars show that using collaborative teams promote high value care and positive outcomes for the populations served.

■ EXEMPLAR 1: INTEGRATION OF EVIDENCE-BASED PRACTICE AT AN ACADEMIC MEDICAL CENTER

Background

Evidence-based practice (EBP) is a systematic problem-solving strategy that integrates high quality, current evidence in conjunction with clinicians’ expertise and patients’ preferences for 424determining patient care (Stannard, 2019). EBP improves the safety, efficiency, and quality of healthcare when used to direct clinical decision-making (Dols et al., 2019; Melnyk & Fineout-Overholt, 2019). Research has demonstrated EBP is better than care based on tradition (Melnyk & Fineout-Overholt, 2019). Melnyk and Fineout-Overholt (2019) reported implementation of EBP contributes to improved quality of care and patient outcomes as well as decreased costs.

Identifying the Problem

Although nurses value EBP, barriers to implementation remain and many nurses do not consistently use evidence in their daily practice (Jun et al., 2016; Melnyk et al., 2016, 2018). Individual barriers to using EBP include perceived lack of time, lack of EBP knowledge and skills, and lack of authority to change practice (McKinney et al., 2019). The most frequently cited and impactful organizational barriers are a lack of administrative and cultural support (e.g., resistance from colleagues, leadership, and other professions) as well as insufficient resources (Duncombe, 2017; Jun et al., 2016). Therefore, the purpose of this project was to increase registered nurses’ (RNs) knowledge of EBP processes and organizational resources available to support practice changes.

Methods to Address the Problem

This project was conducted at a large, academic medical center in Chicago, Illinois. It used a pre-post design involving RNs on six adult inpatient units from the medical, surgical, and psychiatric service lines. The pre-survey was exploratory, designed to identify any gaps in RNs’ understanding and use of EBP so that the intervention could be tailored to the desired outcome.

A 20-item survey was developed to assess RNs’ understanding of how EBP is operationalized, the degree to which they use it in their daily practice, and their ability to make practice changes. The survey was developed based on validated surveys (Melnyk et al., 2008; Pravikoff et al., 2005), then expanded and tailored to the practices and resources at the project site. The survey was developed in collaboration with key stakeholders and found to have face validity by those stakeholders.

Surveys were formatted electronically. A link to the surveys was sent to RNs’ work email addresses. Emails also described the purpose of the survey, indicating participation was voluntary and responses were confidential. A pre-survey was sent June 2016 and a post-survey was sent in July 2017. Returned survey data were compiled automatically then exported to Excel for analysis. Survey responses were anonymous as no unique identifiers were collected.

The pre-survey was sent to 308 RNs with 106 respondents (34.4%). Surveyed RNs reported lacking knowledge of how to change a clinical practice. Specifically, 57.4% (n = 58) did not know how to change clinical practice on their unit if it was not evidence based, and 53.5% (n = 54) did not know how to change an operational standard (policy, procedure, or care plan) if it no longer reflected the best evidence.

A flowchart was developed based on the pre-survey results to provide guidance to RNs on EBP processes and how to change a clinical practice if it is no longer evidence based. It directs RNs to first check institutional policies, procedures and protocols when they have a clinical question, but also to consult evidence-based resources to verify that they reflect current best practice before implementation. If the institutional resources are no longer evidence based, the flowchart directs RNs to the appropriate shared governance committees for changing practice. Supplementary EBP resources are also highlighted as a quick reference.

Additionally, the RNs received a 10-minute unit-based education session covering (a) the pre-survey findings, (b) a review of EBP concepts, and (c) an overview of the flowchart. Educational 425sessions were offered for 2 days on each unit at each day/night shift change to reach as many RNs as possible. Printed copies of the presentation and flowchart were displayed in prominent locations throughout the unit as visual reminders. The flowchart was also uploaded to the nursing intranet for long-term availability.

Evaluation

Descriptive statistics were used to assess demographic characteristics and categorical survey items. Percentage change was calculated to determine the impact of pre-post EBP unit-based education. Survey items with Likert scales were collapsed into dichotomous categories, then Chi-square analysis was used to compare changes before and after implementation. Items with Likert scales for agreement were collapsed into categories of either agreement (strongly agree and agree) or disagreement (strongly disagree and disagree). Five-point scales of frequency were collapsed into categories of minimal occurrence (never and rarely) and more frequent occurrence (sometimes, frequently, and always). Statistical significance was determined using a p-value <0.05 for these data.

Results

Most respondents were BSN-prepared and had more than 5 years of nursing experience. More than half of the RNs were from critical care units with fewer RNs reporting from general medical-surgical units or psychiatry. Some RNs did not respond to all questions. A significant (p < 0.05) increase was found in RNs’ awareness of organizational resources for EBP projects at the project site. Although there was no significant change in RNs’ self-reported knowledge of how to access online resources or ability to access resources in a time-efficient way, there was strong agreement at baseline as well as respective 2.2% and 8.8% increases in agreement on the post-survey. Similarly, there was a 6.9% increase in respondents’ agreement concerning the need to stay up to date with nursing practice by reading research publications. A significant increase was found in RNs’ self-reported confidence to change clinical practice on their units, as well as organizational policies and procedures if they were not evidence-based (p < 0.001).

Discussion

This project aimed to increase RNs’ knowledge of EBP processes and organizational resources available to support practice changes. As reported in Gradone and Staffileno (2019) the most significant changes were in RNs’ self-reported confidence to change clinical practice. This reflected the intended impact of the flowchart and unit-based education sessions, which were to direct RNs through the EBP process and the process of making a practice change if needed. This was consistent with research findings that suggested providing educational courses in a clinical setting can improve RNs’ attitudes and perception of skills related to EBP (Connor et al., 2016; Sim et al., 2016).

This outcome also reflected the importance of organizational support as a facilitator of EBP, which is consistent with other reports in the literature (Lavenberg et al., 2019; Wu et al., 2018). Brockhopp et al. (2016) reported use of their model also highlighted the importance of contacting appropriate administrative groups with the ability to enact change. This is similar to the flowchart for this current project, which directs RNs to the proper shared governance committees with the power to make organizational changes at the medical center.

426Conclusion

Results of this quality improvement project indicated a significant increase in RNs’ self-reported confidence to make EBP changes on their units and at an organizational level. This was consistent with research findings that provision of educational courses in a clinical setting can improve RNs’ attitudes and perception of skills related to EBP (Connor et al., 2016; Sim et al., 2016).

Recommendations for Clinical Practice

APRNs have the requisite knowledge and skills to integrate evidence-based changes into daily practice. Moreover, APRNs are in a key position to guide direct care RNs with responding to clinical questions using the best available evidence to improve patient outcomes.

Summary

This first exemplar highlights key components addressed in Chapter 5, Establishing and Sustaining an Evidence-Based Practice Environment. Essential to the success of this APRN-led project was key stakeholder buy-in, especially organizational support from nursing leadership. Importantly, this project provided unit-based education and access to resources for RNs.

■ EXEMPLAR 2: ENGAGING LONG-TERM CARE RESIDENTS IN WALKING ACTIVITY: A QUALITY IMPROVEMENT PROJECT

Background

Physical activity is recommended for all Americans, including older adults and individuals with chronic conditions (Centers for Disease Control and Prevention, 2019; U.S. Department of Health and Human Services [DHHS], 2018). The health risks related to sedentary lifestyle and potential health benefits routine walking are well known (DHHS, 2018). International experts in geriatrics and physical therapy recommended “reducing sedentary behaviors for all Long-Term Care (LTC) residents” (de Souto Barreto et al., 2016).

Identifying the Problem

Physical inactivity in LTC facilities is prevalent as residents spend almost all of their time sitting or lying (den Ouden et al., 2015; Parry et al., 2019). There is a concern that wheelchair overuse in LTC may contribute to physical inactivity. While the majority of LTC residents have multiple chronic conditions (Moore et al., 2014), physical inactivity may further exacerbate declining health (Patterson et al., 2018), cognitive abilities (Ku et al., 2017; Tan et al., 2017), and bone mass (Rodriguez-Gómez et al., 2018). There are several studies and clinical guidelines suggesting that moderate levels of physical activity may have significant positive impacts on body systems, regardless of gender or age (Frändin et al., 2016; HHS, 2018; Schnelle et al., 2003; Soares-Miranda et al., 2016) and mortality reduction (Esteban-Cornejo et al., 2019; DHHS, 2018). One LTC inner-city facility had a Walk-to-Dine program, but it was offered to residents inconsistently. Therefore, the purpose of this project was to engage eligible LTC residents into participating in daily self-paced walking to promote physical activity.

427Methods to Address the Problem

The Model for Improvement with its Plan-Do-Study-Act method (Langley et al., 2009), recommended by the Institute for Healthcare Improvement (n.d.), was used as a framework to guide this project. The APRN-project lead identified key stakeholders and obtained a letter of support from senior LTC facility leadership. A literature review helped identify an evidence-based walking program for LTC residents (MacRae et al., 1996; Schnelle et al., 2002; Schnelle et al., 1995). Additional interventions were selected to support the implementation of a consistent walking program including (a) an environment and policy assessment, (b) identifying a champion, (c) staff training, and (d) mentoring and motivating (Galik et al., 2014; Taylor et al., 2015). The LTC facility’s leadership commitment and support allowed securing the resources essential for the project implementation. A critical step in the planning phase was the assessment of all residents for eligibility and enrollment in a walking program that was provided 5 days a week. The APRN-project lead, with input from the facility’s staff, designed the tools to collect data and manually completed data collection. The first assessment was completed based on a mobility screening questionnaire used in previous research studies (Schnelle et al., 1995). Then, the final eligibility of residents for a walking program was assessed during walking trails. The project was implemented on one floor of the LTC facility over 20 weeks. It was monitored closely by the APRN-project lead and a facility champion-restorative nurse.

Evaluation

The process evaluation was ongoing and focused on three sections of the Logic Model-inputs, activities, and outputs (W. K. Kellogg Foundation, 2017). The evaluation included questions and measures to describe how the walking program was working and why. The main measures were designed to describe the impact of walking activity on residents enrolled in the program.

Results

All staff participated and completed education about the walking program and its potential benefits. Among the 78 residents screened, 17% (n = 13) were eligible and enrolled in the walking program whereas severe functional decline and/or physical disability were the primary reasons for exclusion. Of all enrolled residents, 77% were identified with severe or moderate cognitive impairment with the Brief Interview for Mental Status assessment score between 6 and 12, the majority were African American (70%), female (62%), and 70 years of age (ranging from 42–91). The residents’ length of stay at the LTC facility was between 6 months to 6 years. As reported by Kazana and Pencak Murphy (2018), after 20 weeks, 69% (n = 9) of residents continued their participation in the walking program. None of the residents experienced a fall or any acute symptoms during walking activity. None of the residents stopped participation in the walking activity due to dissatisfaction with the program. With respect to walking, 77% of the residents were provided the activity at least 60% of the time, 23% of the residents only one to two times per week, and no residents received the activity 100% (or five times a week) as intended.

Discussion

The project results supported feasibility of a walking program implementation for LTC residents and demonstrated that residents tolerated walking well without any adverse events during activity. Our observations were consistent with Danilovich et al. (2017) who claimed that even frail 428older adults tolerated high-intensity walking activity well. In addition, Fien et al. (2019) reported that LTC residents in their 80s, cognitively impaired, using a walker or a cane tolerated a structured exercise program and increased their gait speed. One of our unanswered questions was why 23% of the residents were provided activity only one to two times a week. Kuk et al. (2018) suggested that gaps in communication and lack of accountability within teams had strong negative effect on promoting functional activity in LTC, possibly more than short staffing. Thus, multiple changes in management and senior leadership in our LTC facility during the project planning and implementation might have been a contributing factor.

Conclusion

While challenges to implement a sustainable walking program for LTC residents may arise from multiple organizational factors (Douma et al., 2017), they can be mitigated with leadership support and staff engagement (Slaughter et al., 2018). Often, the residents with chronic pain, dementia, or physical frailty can do more than they or healthcare providers think they can do. While walking activity has a potential for maintaining or even improving residents’ functional status (Frändin et al., 2016; DHHS, 2018; Schnelle et al., 2003), acute decline in walking distance or in gait speed might be an early signal of change in a resident’s health (Danilovich et al., 2017). Usually restorative nurses oversee physical activity of LTC residents, and nurse assistants play an instrumental role in daily care provided to the residents. However, implementation of a sustainable and effective walking program requires commitment and ongoing support from LTC providers, including nurse practitioners, and LTC leadership (Kagwa et al., 2018).

Recommendations for Clinical Practice

APRNs can play a critical role in engaging LTC residents in walking activity. First, APRNs working in LTC can recommend or even prescribe physical activity when it is appropriate. Also, many APRNs, especially those doctorally prepared, can lead transformation efforts and become quality improvement (QI) project leaders. In addition, by implementing resident-centered components with measuring the distance (Kazana & Pencak Murphy, 2018) or the time residents walk could enhance understanding of those residents’ well-being overall (Middleton et al., 2015).

Summary

This exemplar highlights content from Chapter 4, Continuous Quality Improvement. A key component for any practice change is to evaluate its impact on patient outcomes and processes. This APRN-led project incorporated a continuous QI model to guide the Plan, Do, Study, Act phases as described.

■ EXEMPLAR 3: FALL PREVENTION PROGRAM IN AN ASSISTED LIVING FACILITY

Background

Among adults 65 and older, falls are the seventh highest cause of death and the leader in fatal and non-fatal injuries (Bergen et al., 2016; Burns & Kakara, 2018). When compared to community-dwelling older adults, assisted living facility (ALF) residents are at a greater risk of falling due to a higher level of care needs and functional dependence (Kistler et al., 2016; Matthews et al., 2016; 429Towne et al., 2017

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